Rural Mandal, East Godavari District, A.P., 533124. .. Complainant
And
1) Konmu Aneesh, Agent of Birla Sunlife Insurance Co. Ltd.,
R/o. D.No.45-22-20/3, Top Floor, Raj Towers, Tadi Thota
Junction, Rajahmundry.
2) M/s. Birla Sun Life Insurance Co. Ltd., Rep. by its Managing
Director, One India bulls center, Tower 1, 15th and 16th Floors,
Jupiter Mill Compound, 841, Senapati Bapat Marg, Elphin Stone
Road, Mumbai – 400 013.
3) M/s. MD India Healthcare Services (TPA) Pvt. Ltd.,
Rep. by its Managing Director, S.No.46/1, E – Space, A2 Building,
4th Floor, Pune nagar Road, Vadgaonsheri, Pune – 411 014.
4) M/s. Birla Sun Life Insurance Co. Ltd., Rep. by its Manager,
Beside HDFC Bank, Danavaipeta, Rajahmundry. .. Opposite parties
This case coming on 04.12.2015 for final hearing before this Forum in the presence of Sri M. Siva Surya Kumar, Advocate for the complainant and the case against 1st opposite party is dismissed and the opposite parties 2 to 4 having been set exparte, and having stood over to this date for consideration, this Forum has pronounced the following:
O R D E R
[Per Sri S. Bhaskara Rao, Member]
This is a complaint filed by the complainant U/Sec.12 of Consumer Protection Act 1986 to direct the opposite parties 2 to 4 to pay an amount of Rs.3,71,809/- towards medical reimbursement amount which is payable under the Policy No.004903534; to pay an amount of Rs.2,00,000/- towards compensation for mental agony; to pay interest thereon from the date of complaint till the date of realization at the rate of 24% p.a. and to pay Rs.25,000/- towards costs.
2. The case of the complainant is that she obtained a Health insurance policy No.004903534 from the 2nd opposite party on 31.5.2011 for a period of 3 years through the 1st opposite party who is the agent of the 2nd opposite party and she paid all the premium amounts to the 2nd opposite party without any default. During the term of the said policy, the complainant was hospitalized due to kidney problem and she underwent surgery for kidney transplantation at Sradha Hospital, Visakhapatnam. She admitted in the hospital on 19.11.2013 and discharged on 4.12.2013. She incurred an amount of Rs.3,71,809-50ps for her surgery and post operation, medical expenses in the hospital besides other expenses and she informed the same to the 2nd opposite party and made a claim dt.10.12.2013 claiming her medical expenses incurred and sent all the required documents to the 2nd opposite party. Though, the complainant requested the 3rd opposite party several times to pay the claim amount, but the 3rd opposite party did not settle the claim. The complainant sent consultation papers to the 3rd opposite party on their request. Finally, the complainant got issued a legal notice on 23.10.2014 to the 2nd and 3rd opposite parties received the notices and the 2nd opposite party gave a reply on 10.2.2015 stating that “to submit all investigation reports related to kidney disease started with on consultation reports.” Hence, there is no other go, she filed this complaint.
3. The claim against the 1st opposite party is not pressed by the complainant and so, dismissed and the opposite parties 2 to 4 remained exparte despite receipt of notices from this Forum.
4. The proof affidavit filed by the complainant and Exs.A1 to A13 have been marked.
5. Heard, the complainant.
6. Points raised for consideration are:
1. Whether there is any deficiency in service on the part of the opposite parties 2 to 4?
2. Whether the complainant is entitled for the reliefs asked for?
3. To what reliefs.
7. POINT Nos.1 & 2: On perusal of the record, it is observed that the complainant herein obtained own life insurance health plan vide Policy No.004903534 with client ID No.0821976851 on 31.5.2011 with effect from the same date for 3 years and the expiry date of the said policy is 31.5.2014 on payment of quarterly premium of Rs.2,292-77ps as per first premium receipt under Ex.A1 through the 1st opposite party agent at Rajahmundry. The 2nd and 4th opposite parties are the head office and branch through which their insurance business was carried on. The 3rd opposite party is the third party administrator based at Pune for the policies issued by the 2nd opposite party Birla Sun Life Insurance Company Limited, Mumbai. The complainant herein hospitalized due to kidney problem and underwent surgery for kidney transplantation from 19.11.2013 to 4.12.2013 at Sarada Hospital, Visakhapatnam, for which the complainant incurred an amount of Rs.3,71,809-50ps and informed the same to the 2nd opposite party under claim No.CCN: MD11758506 on 10.12.2013 along with all the required documents through the 3rd opposite party vide Ex.A2 claimant’s statement, Ex.A3 hospital treatment certificate issued by Sarada Hospital, Visakhapatnam, medi-claim medical report with claim form under Ex.A4 and Ex.A5 medical bills.
Then, the 3rd opposite party requested the complainant to send the first consultation paper and other papers and accordingly, the complainant sent all the papers to the 3rd opposite party on 11.1.2014 vide Ex.A11 first consultation prescription dated 30.11.2011, Ex.A12 consultation on 29.3.2013 and referral letter under Ex.A13. But, the 3rd opposite party dragged the reimbursement process though all the required papers were sent to them by the complainant. The 3rd opposite party once again on 7.3.2014 asked the complainant to send first consultation paper with findings showing the nature/duration/ history of illness along with the referral letter for investigation or specialist consultation paper and all subsequent consultation papers along with investigation reports pertaining to the diagnosis and treatment of diabetes, hypertension, hepatitis and kidney diseases. The complainant made correspondence through email vide Ex.A6 and Ex.A7 on 19.8.2013, 29.8.2013, 19.12.2013, 23.12.2013 with the opposite parties to reimburse the expenditure incurred for surgery, but the opposite parties intentionally prolonged the reimbursement process causing mental agony, inconvenience without settling the claim. The 3rd opposite party informed the complainant through email on 10.3.2014 that they have received the additional documents and they will update the status to the complainant, but did not take any steps to reimburse the claim of the complainant.
On that, the complainant got issued a legal notice dt.23.10.2014 under Ex.A8 to the 2nd & 3rd opposite parties demanding to pay the medical reimbursement of Rs.3,71,809-50 ps and to pay an amount of Rs.2,00,000/- for the loss suffered by the complainant due to the negligence of the opposite parties. The 2nd & 3rd opposite parties received the notices vide acknowledgements under Ex.A9 and the 2nd opposite party replied on 10.2.2015 vide Ex.A10 to submit all investigation reports related to kidney disease with all the consultation papers, which were already sent by the complainant and so, the complainant constrained to file this complaint in this Forum.
We observed that the complainant herein submitted all the required documents to the 2nd & 3rd opposite parties for processing of her medical reimbursement claim from initial consultation under Ex.A11 from Dr. S. Nemani, Rajahmundry and further consultation vide Ex.A12 and the doctors certificate of first consultation that he found that the complainant have chronic renal failure. So, it is deemed that the complainant sent all the required documents to settle the medical reimbursement claim for her treatment and surgery at Visakhapatnam. Further, we also observed that there is a lot of correspondence made by the complainant in this regard with the opposite parties towards claim settlement, but the claim of the complainant was not settled by the opposite parties and dragged the matter up to this stage without any fault on the part of the complainant. The opposite parties 2, 3 & 4 though received the notices from the District Consumer Forum, they failed to turn up to submit their version and remained exparte throughout this proceedings. The acts of the 2nd & 4th opposite parties insurance company and the 3rd opposite party third party administrator amounts to negligence and deficiency of service and the 2nd & 4th opposite parties are liable to pay the medical reimbursement claim of Rs.3,71,809-50 ps along with interest from the date of this complaint and costs of the complaint. The complainant is not entitled for any compensation asked for.
8. POINT No.3: In the result, the complaint is allowed, directing the 2nd & 4th opposite parties Birla Sun Life Insurance Company Limited to pay Rs.3,71,809-50ps towards medical reimbursement under Birla Sun Life Insurance Health Plan with interest @ 9% p.a. from the date of complaint i.e. 31.08.2015 to the complainant. We further direct the 2nd & 4th opposite parties to pay Rs.2,000/- towards the costs of the complaint to the complainant. The claim against the 1st & 3rd opposite parties is dismissed. Time for compliance is two months from the date of this order.
Typed to dictation, corrected and pronounced by us in open Forum, on this the 10th day of December, 2015.
Sd/-xxx Sd/-xxx
MEMBER PRESIDENT(FAC)
APPENDIX OF EVIDENCE
WITNESSES EXAMINED
FOR COMPLAINANT: None. FOR OPPOSITE PARTIES: None.
DOCUMENTS MARKED
FOR COMPLAINANT:
Ex.A1 Health insurance Policy No.004903534 along with premium receipt (attested copy)
Ex.A2 Claimant Statement for Reimbursement claim. (attested copy)
