Date of Filing ::24-05-2012
Date of Disposal ::14-07-2015
BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM::ONGOLE
Friday, this the 14th day of July, 2015
PRESENT: Sri P.V. Krishna Murthy, B.A.,B.L., President
Sri K. UMAMAHESWARA RAO, M.A.,B.L., Member
C.C.No.37/2012
Kuruvella Venkata Nageswara Rao,
Son of Mallikharjuna Rao,
Aged about 52 years,
LIC agent, R/o Door No.37-1-434-24,
1st line, Ram Nagar,
Ongole Corporation,
Prakasam District. … Complainant
Vs.
1) The Divisional Manager,
M/s Oriental Insurance Company Limited,
S.B.H., Uptstairs, Santapet, Ongole,
Prakasam District.
2) MD India Healthcare Services (TPA) Pvt., Ltd.,
# 701 & 702, 7th Floor, Topaz Building,
Punjagutta, Hyderabad- 500 082. …Opposite Parties
This complaint coming on 03-07-2015 before us for hearing in the presence of Sri S.V. Mallikharjuna Rao, Advocate for the Complainant and Sri Pavani Sree Ramaiah, Advocate for the first opposite party and second opposite party remained ex-parte and having stood over for consideration till this day and this Forum made the following:
ORDER
(ORDER BY Sri P.V. KRISHNA MURTHY, PRESIDENT)
1. The brief averments of the complaint are as follows:
The complainant obtained health insurance policy from the 1st opposite party since 2006 and it continued till 2010. He obtained the same through 2nd opposite party. The wife of the complainant was suffering with back pain from 10-04-2011. The complainant informed the 1st opposite party and got her admitted in Sekhar Ortho & Neuro Centre, Vijayawada, for treatment. The wife of the complainant was under treatment till 02-07-2011. More than Rs.52,200/- was paid for the treatment. The complainant submitted all the medical bills to the 1st opposite party. But, the claim was not settled. The same is deficiency of service. Hence, the complaint for payment of insurance amount with costs and damages.
2. The brief averments of the counter of the 1st opposite party are as follows:
The complaint is not maintainable. The allegations made in the complaint are not correct. The opposite party is only a premium collector. The financial position rests with the 2nd opposite party. This opposite party sent all the letters to the 2nd opposite party for settlement of the claim. The 2nd opposite party repudiated the claim on the ground that the patient was treated on OPD basis. As per clause-4.23, outpatient diagnostic treatment was excluded and the complainant is not entitled for reimbursement. The policy was repudiated rightfully. There is no deficiency of service. Hence, the complaint may be dismissed.
3. The 2nd opposite party did not contest the matter.
4. Now the point for consideration is “Whether the opposite parties committed a deficiency of service?”
5. The complainant filed her affidavit and marked Exs.A1 to A9. No evidence was adduced by the opposite parties.
6. POINT:- The coverage by insurance is admitted. The complainant took health insurance policy from the 1st opposite party. The contention of the 1st opposite party that it has nothing to do with the claim and that the 2nd opposite party alone has the right to accept the claim or reject the claim, cannot be accepted. The mediclaim insurance is between the insurance company and the patient. On that ground alone, the 1st opposite party cannot escape its liability. The next contention of the 1st opposite party is, that the complainant took treatment as outpatient and as such, the claim cannot be allowed. The mediclaim policy is marked as Ex.A5. Column-4.23 of Ex.A5 excludes “Outpatient diagnostic, medical and surgical procedures or treatments, non-prescribed drugs and medical supplies, hormone replacement therapy, sex change or treatment, which results from or is in any way related to sex change”. The opposite party is relying upon this clause in rejecting the claim of the complainant.
Ex.A2 is the case sheet with regard to the patient, Smt. Parameswari, wife of the complainant. In Ex.A2, it was mentioned that the patient was admitted on 27-4-2011 and was discharged on 02-07-2011. This document rejects the contention of the opposite party. It shows that the wife of the complainant received treatment as in-patient of that hospital. Clause-4.23 of Ex.A5 is not applicable to this case. Except the said clause there is no other ground to reject the claim of the complainant. The first opposite party relied upon clause-4.23 in para 6 of the counter filed by them. Since the wife of the complainant received treatment as inpatient, the 1st opposite party has to reimburse the medical expenses as per the contract of insurance. Rejecting the claim on an untenable ground amounts to deficiency of service. Since the opposite party committed deficiency of service, the complainant is entitled to the amount on medical expenses. The complainant might have suffered mental agony when the claim was rejected. An amount of Rs.5,000/- can be granted as compensation towards mental agony along with costs of Rs.3,000/-. The point is held accordingly.
7. In the result, the complaint is allowed, directing the opposite parties to pay Rs.52,200/- (rupees fifty two thousand and two hundred only) to the complainant with interest at 9% P.a. (nine) from the date of complaint i.e., 24-05-2012 till realization along with compensation of Rs.5,000/- (rupees five thousand only) and costs of Rs.3,000/- (rupees three thousand only).
Dictated to the Stenographer, transcribed by him and corrected and pronounced by us in the Open Forum this the 14th day of July, 2015.
Sd/-xxx Sd/-xxxx
MEMBER PRESIDENT
APPENDIX OF EVIDENCE
WITNESS EXAMINED FOR COMPLAINANT:
P.W.1 24-05-2012 Kuruvella Venkata Nageswara Rao, S/o
Mallikharjuna Rao, Aged about 42 years, LIC agent, R/o Door No.37-14-434-24,
1st line, Ram Nagar, Ongole Corporation,
Prakasam District.
WITNESS EXAMINED FOR OPPOSITE PARTY:
-NIL-
EXHIBITS MARKED FOR COMPLAINANT:
Ex.A1 23-04-2011 Photostat copy of the written representation by the
complainant’s wife to the 2nd opposite party for treatment along with courier receipt.
Ex.A2 01-08-2011 Photostat copy of written representation by the
complainant to the 2nd opposite party along with courier receipt and Photostat copies of the case sheet, illness details, treatment bill discharge summary, investigation reports and claim form.
Ex.A3 18-10-2011 Photostat copy of the written representation by the
complainant to the 2nd opposite party along with courier receipt and Photostat copy of the case sheet.
Ex.A4 10-02-2012 Photostat copy of written representation by the
complainant to the both opposite parties along with postal receipts and service acknowledgments.
Ex.A5 True copy of the terms and conditions of the
mediclaim insurance policy issued by 1st opposite party.
Ex.A6 Photostat copy of cash receipts(3) issued by Sekhar
Ortho & Neuro Centre, Vijayawada.
Ex.A7 15-12-2011 Photostat copy of the e-mail copy sent to the 2nd
opposite party by 1st opposite party.
Ex.A8 26-03-2012 Office copy of the legal notice with postal receipts.
Ex.A9 Service acknowledgments (2 Nos).
EXHIBITS MARKED FOR OPPOISTE PARTIES:
-NIL-
Sd/-xxxx
PRESIDENT
Copies to:
1) Sri S.V. Mallikharjuna Rao, Advocate, Ongole.
2) Sri Pavani Sree Ramaiah, Advocate, Ongole.
3) MD India Healthcare Services (TPA) Pvt., Ltd.,
# 701 & 702, 7th Floor, Topaz Building,
Punjagutta, Hyderabad- 500 082.
Date when free copy was issued:
//True Copy//
