O R D E R
(By Sri A. Radha Krishna, President on behalf of the Bench)
1. The complainant sought Rs. 1,13,500/- for loss sustained by her and subsequent interest on Rs. 1,00,000/- and for costs of the complaint on the ground of deficiency of service on the part of the opposite parties.
2 It is the version of the complainant she has taken medical insurance policy from 1st opposite party under “HAPPY FAMILY FLOATER POLICY SCHEDULE” on 14.07.2011. At the time of obtaining the policy she chose the option of cashless settlement foregoing 5% commission on the premium amount. She paid Rs.44,175/- and the 1st opposite party issued policy which was in force from 14.07.2011 to 13.07.2012. Under the policy the entire family members of the complainant are covered. The insured are entitled to cashless settlement for hospitalization charges and surgical expenses etc.
3 According to her, her father-in-law Ch. China Veerraju was admitted in Apollo Hospital, Kakinada on 03.12.2011 with acute LVF and underwent treatment as in patient and died on 07.12.2011. It is also her version after joining her father-in-law in hospital she sent claim form to the opposite parties for cashless settlement. But she received a letter from the 2nd opposite party on 08.12.2011 seeking to provide exact details of any past episode of card etc. Again the 2nd opposite party called her to provide previous four years policy copies. She informed them that she is an old customer and all the records are available with them. The opposite parties did not stick on to the terms and conditions of the policy. Due to the negligence of the opposite parties, she had to pay of Rs. 66,000/- towards hospital bills apart from other pharmacy bills. Thus according to her the act of the opposite parties are nothing but deficiency of service and unfair trade practice. Inspite of repeated demands the opposite parties did not settle her claim. She also issued a registered notice to the opposite parties demanding Rs. 1,00,000/- together with interest. Having received the same, they kept quiet.
4 The 2nd opposite party remained exparte and the 1st opposite party filed its written version denying the material allegations attributed against them. They admit the complainant taking policy covering the family members and admitting the father- in-law of the complainant in Apollo Hospital, Kakinada on 03.12.2011 and his death and also the payment of Rs. 66,000/- made by the complainant. But according to them the claim was raised only subsequent to payment of the amount by the complainant and in fact after coming to know of the claim the 1st opposite party after perusing the records available with the 2nd opposite party they settled the claim at Rs. 66,000/- and sent discharge voucher to the complainant, but she refused the settlement and demanded the payment claimed by her in her legal notice. Thus according to them there is no deficiency of service at all as the complainant did not sent her claim forms before her making payment.
5 Now the points for determination are:
- Whether there is any deficiency of service on the part of the opposite parties as claimed by the complainant?
- If so, whether the complainant is entitled for any amount sought by her in the complaint?
6. Point No.1: To prove her case the complainant filed her proof affidavit and exhibited documents. Ex.A1 is the Xerox copies of policy, Ex.A2 is a receipt evidencing payment of premium amount, Ex.A3 is copy of inpatient bill issued by Apollo Hospital, Kakinada, Ex.A4 is office copy of lawyer’s notice and Ex.A5 is postal acknowledgment of 1st opposite party.
7. On the other hand the 1st opposite party filed proof affidavit of its Divisional Manager reiterating their case as set out in the written version and got marked office copy of letter addressed by them to the complainant and the reply received from the complainant.
8. As seen from the above material what is clear is that the complainant obtained policy from the 1st opposite party covering the family members also. The death of father-in-law of the complainant after admitting into hospital with illness and also payment of Rs. 66,000/- by the complainant towards hospital charges are not disputed. Though the complainant claims immediately after joining her father-in-law in the hospital, she sent claim form for which she received letter from 2nd opposite party on 06.11.2013 seeking some information she did not produce any material to support her version. Though she claims the 2nd opposite party addressed a letter dt. 06.12.2013 to her she has not filed any such letter addressed by the 2nd opposite party to her.
9 Here it is the contention of the 1st opposite party that infact before payment of hospital charges she did not send any claim to them and but now asking them to pay compensation and hence they are not liable to pay any amount. Thus it is manifest the complainant failed to produce any material showing her intimating the joining of her father-in-law in Apollo Hospital, Kakinada and submitting claim form for cashless settlement. It is not in dispute the complainant made payment of Rs.66,000/- to hospital authorities. It is not out of context to mention here that the very policy cashless settlement indicates that it is the duty of the complainant to raise claim for cashless settlement as soon as she joined her father-in-law in Apollo Hospital, Kakinada. Thus after making payment, demanding to 1st opposite party to make good the loss is contra to the terms and conditions of the policy. Infact the 1st opposite party after ascertaining the details from the 2nd opposite party settled the claim of the complainant at Rs. 66,000/- which amount is paid by her for treatment. As seen from Ex.B2 the reply letter from the complainant to the 1st opposite party, she declined to accept the said amount. Hence under these circumstances there is no fault on the part of the opposite parties for making them liable for any deficiency of service as demanded by the complainant. Thus without receiving that amount the complainant approaching this Forum is not at all in consonance with the terms and conditions of the policy. Thus in the circumstance there is no deficiency of service on the part of the opposite parties. Thus this point is answered accordingly.
10. Point No.2: In view of the finding rendered under point No.1 the complainant is not entitled for any amount as sought by her. Thus this point is answered accordingly.
11. Point No.3: In the result the complaint is dismissed in the circumstances without costs.
Dictation taken by the Steno, transcribed by her, corrected and pronounced by us, in open Forum, this the 23rd day of January, 2015.
Sd/- xxxx Sd/- xxxxxxx
MEMBER PRESIDENT
APPENDIX OF EVIDENCE
WITNESSES EXAMINED
For complainant :
PW1: Sri Chandalada Jaggayamma [Complainant ]
For opposite parties:
RW1: Sri Chakradhara Rao, Divisional Manager, Oriental Insurance Co. Ltd., Kakinada
DOCUMENTS MARKED
For complainant:-
Ex.A1 13.07.2011 Policy schedule [Photostat copy]
Ex.A2 13.07.2011 Payment premium receipt [Photostat copy]
Ex.A3 08.12.2011 Inpatient bill issued by the Apollo Hospital, Kakinada [Photostat Copy]
Ex.A4 21.01.2012 Office copy legal notice issued by the complainant to opposite parties [original]
Ex.A5 Acknowledgment [original]
For opposite parties:-
Ex.B1 Letter addressed by the 1st opposite party to the complainant [original]
EX.B2 19.03.2012 Reply given by the complainant to 1st opposite party [original]
Sd/- xxxx Sd/- xxxxxxx
MEMBER PRESIDENT
