BEFORE THE A.P STATE CONSUMER DISPUTES REDRESSAL COMMISSION AT HYDERABAD.
F.A. 910/2008 against C.C. 967/2007, Dist. Forum-I, Hyderabad.
Between:
M/s. National Insurance Company Ltd.
Rep. by its Regional Manager
Hyderabad Regional Office
5-4-183, 3rd Floor,
Twin Citi Market Complex
M.J. Market, Hyderabad-1. *** Appellant/
Opposite Party
And
1. Misrilal Sharma,
S/o. Bhikraj Sharma
Age: 63 years,
R/o. 21-7-487
Shakker Kota Charkaman
Hyderabad-500 002.
2. Smt. Geeta Bai (Died) *** Respondents/
Complainants
3. M/s. Vijaya Bank
Rep. by its Branch Manager
Charminar Branch,
Gulzar House,
Charminar, Hyderabad. *** Respondent/
O.P. No. 2
4. Babita Mishra,
W/o. Suresh Mishra
Age: 40 years, R/o. 15-5-371
Baider Wadi, Begum Bazar
Hyderabad.
5. Rekhar Tiwari,
W/o. Niranjanlal Tiwari
38 years, Teacher,
R/o. 15-7-130, Bhagwan Gunj,
Begum Bazar, Hyderabad.
6. Vishnu Sharma
S/o. Misrailal Sharma
36 years, Advocate
R/o. 21-7-487, Shakker Kota
Charkaman, Hyderabad.
7. Uma Sharma,
W/o. Pradeep Sharma
32 years, Flat No. 103
Vijetha Castle,
H.No. 16-2-147/4, Anandnagar
Malakpet, Hyderabad.
8. Poonam Sharma,
W/o. Shankerlal Sharma
27 years, R/o. 21-7-474
Shakker Kota, Hyderabad.
LRs; added as per orders in
FAIA No. 373/2010 Dt. 6.4.2010. *** Respondents/
Complainants.
Counsel for the Appellant : M/s. Kota Subba Rao
Counsel for the Respondent: M/s. Sucharita Gahaloth (R1)
CORAM:
HON’BLE SRI JUSTICE D.APPA RAO, PRESIDENT.
&
SMT.M.SHREESHA, LADY MEMBER.
THURSDAY, THE SIXTEENTH DAY OF SEPTEMBER TWO THOUSAND TEN
ORAL ORDER: (Per Hon’ble Sri Justice D. Appa Rao, President.)
***
1) This is an appeal preferred by the insurance company against the order of the Dist. Forum directing it to pay Rs. 1,41,03/- along with R2 together with interest @ 12% p.a., from the date of complaint till the date fo realization.
2) The case of the complainants in brief is that they opened an S.B. account with Vijaya Bank R2 wherein they were covered by health insurance under V. Arogyabhima policy for an amount of Rs. 1 lakh covering the period from 7.3.2006 to 6.3.2007. The premium was deducted from their account and they were issued an identity card indicating that they are covered by medi-claim policy. While so on 3.10.2006 she developed stomach pain and vomiting. She was taken to Hariprasad Memorial Hospital, Pathergatti where she was admitted as in-patient on payment of Rs. 4,500/- towards charges and thereafter she was referred to Kamineni Wockhardt hospital on 4.10.2006 where investigations including Ultra sonography were done. The doctors advised surgery for intestinal obstruction and cholelithiasis. A pre-authorization letter was sent to meet the medical expenditure by sending in Form-22 from the hospital. It in turn requested to furnish the record relating to the past history and duration of the ailment etc. However, the hospital authority insisted unless the amount was deposited it refused to proceed with the surgery. As necessary certificates were not given she was shifted to Aroygya Hospital at M.J. Market and got the operation conducted by incurring an expenditure of Rs. 76,558/-. A letter was addressed on 21.12.2006 to reimburse the amount, however, even after lapse of five months it had failed to reimburse the payment and therefore filed the complaint to recover Rs. 76,350/- towards reimbursement of claim, Rs. 13,743/- towards interest @ 18% p.a., and interest @ 12% p.a., on Rs. 76,350/- from the date of complaint till the date of payment together with compensation of Rs. 50,000/- towards mental agony and Rs. 1,000/- towards costs.
3) The insurance company resisted the claim. While admitting issuance of policy however it alleged that the claimant is a hypertensive patient on regular treatment with history of hysterectomy. The patient was investigated and diagnosed as calculus cholecystitis, Saio, HTN having i) SAIO- secondary adherious with past history of hysterectomy ii) Cholelithiasis. The said ailment does not fall under the purview of the policy as it was pre-existing. The Third Party Administrator (TPA) on receipt of the claim informed that the ailment was pre-existing. It is violative of clause 4.1 of the terms and conditions of the policy wherein the assured had to disclose the pre-existing ailments. After receipt of report immediately they have informed that the claim was not admissible since the ailment was pre-existing and therefore they were not liable to pay any of the amounts claimed and prayed for dismissal of the complaint with costs.
4) The complainants in proof of their case filed affidavit evidence and got Exs. A1 to A61 marked while the appellant filed the affidavit evidence of its Deputy Manager and got Exs. B1 to B6 marked.
5) The Dist. Forum after considering the evidence placed on record opined that the insurance company had failed to prove that the abdominal pain which led to operation for cholicystitis and intestinal obstruction and choelithiasis was on account of earlier hysterectomy operation and that she was suffering from pre-existing ailment and the repudiation was unjust and therefore directed the insurance company together with R2 bank to pay Rs. 1,41,093/- with interest @ 12% p.a., from the date of complaint till the date of realization.
6) Aggrieved by the said decision, the insurance company preferred this appeal contending that the Dist. Forum did not appreciate either facts or law in correct perspective. It ought to have seen that the assured had suppressed her previous ailments. She had hypertension therefore not eligible to take the policy. The original claim was for Rs. 76,350/-. The maximum coverage was Rs. 1 lakh, however award was passed for Rs. 1,41,013/- with interest @ 12% p.a., and therefore prayed that the order of the Dist. Forum be set-aside.
7) The point that arises for consideration is whether the order of the Dist. Forum is vitiated by mis-appreciate of fact or law?
8) It is an undisputed fact that the assured was covered by V-Arogya Bima Policy Ex. A1 for the period from 7.3.2006 to 6.3.2007 for Rs. 1 lakh. On 3.10.2006 when she developed abdominal pain she went to Hariprasad Memorial hospital where various tests were conducted evidenced under Exs. A4 to A13. Later she was shifted to Kamineni Wockhardt hospital and after conducting various tests evidenced under Exs. A14 to A35 she was diagnosed that there was intestinal obstruction and choelithiasis. When pre-authorization form was sent to the appellant insurance company, and when they did not issue the hospital refused to perform the operation and she was forced to undergo operation at Arogya Hospital at M.J. Market by spending Rs. 76,558/- evidenced under bills. When claim was made the insurance company repudiated under Ex. B2 letter on the ground that medical team has opined for rejection of these claims. It did not give any reasons. No doubt she underwent hysterectomy long prior to taking of the policy. The doctors opinion obtained by the insurance company under Ex. B3 no where mentioned that acute intestinal obstruction was due to earlier adhesions of hysterectomy. No doubt the said fact was made a mention but there was no expert opinion to show that the acute intestinal obstruction was due to earlier hysterectomy. It has no relevancy whatsoever. The insurance company has been searching for some ruse to deny the just claim of the complainant. Therefore, we are of the opinion that the insurance company was wrong in not issuing pre-authorization form as required under Form-22 to the hospital to conduct surgery on the complainant that made her to go to Arogya Hospital where she had spent Rs. 76,350/- towards operation and other charges. This is covered by various documents, bills etc., filed by the complainant. This amounts to deficiency in service on the part of insurance company.
9) The complainant while claiming this amount also claimed interest @ 18% p.a., viz., 13,743/- from the date of claim till the date of complaint. She also claimed interest 12% p.a., on Rs. 76,350/- from the date of complaint till the date of payment. The Dist. Forum without considering the maximum coverage under the policy awarded Rs. 1,41,093/- directed the said amount to be paid again with interest @ 12% p.a., from the date of complaint till the date of realization. This awarding of Rs. 1,41,093/- with interest @ 12% p.a., is unjust. It could not have awarded more than Rs. 1 lakh as the coverage of insurance is Rs. 1 lakh only. Therefore it requires modification.
10) In the result the appeal is dismissed except for modification directing the appellant to pay Rs. 76,350/- together with interest @ 9% p.a., from the date of claim viz., from 26.10.2006 till the date of realization with costs of Rs. 2,000/-. Time for compliance four weeks.
1) _______________________________
PRESIDENT
2) ________________________________
MEMBER
Dt. 16. 09. 2010.
*pnr
“UP LOAD – O.K.”
