Andhra Pradesh

Visakhapatnam-II

CC/296/2012

Atreyapurapu Narayana Rao - Complainant(s)

Versus

M/s The New Inida Assurance Company Limited - Opp.Party(s)

A.V.C.N. Nageswara Rao

09 Dec 2014

ORDER

                                              Date of Registration of the Complaint:20-09-2012

                                                                                                Date of Order:09-12-2014

BEFORE THE DISTRICT CONSUMERS FORUM-II AT

                             VISAKHAPATNAM

 

P  r  e  s  e  n  t:

1.Sri H. Ananda Rao, M.A., L.L.B.,

     President           

2. Smt K. Saroja, M.A. B.L.,

     Lady Member 

                                3. Sri C.V. Rao,  M.A., B.L.,

                                     Male Member

 

                          Tuesday, the 9^th day of December, 2014.

                                 CONSUMER CASE No.296/2012

Between:-

Atreyapurapu Narayana Rao,

S/o late Krishna Murthy, Hindu, aged 50

years, residing at 8-3-4/2, 1^st floor Flat No.1,

Palace Heights Apartment A, Palace layout,

Pedawaltair, Visakhapatnam-17.

….. Complainant

And:-

The New India Assurance Company Limited,

rep. by its Divisional Manager, Divisional Office:III,

D.No.49-01-09, II floor, Dali Raju Super Market,

Sangam Office Bus Stop, Akkayyapalem Main Road,

Visakhapatnam-16

                                                                                      …  Opposite Party        

                     

          This case coming on 28.11.2014 for final hearing before us in the presence of Sri  A.V.C.N. Nageswara Rao and Y.K.M. Laxmi, Advocates for the Complainant and Sri D. Siva Prasad, Advocate for the Opposite Party and having stood over till this date for consideration, this Forum made the following:

 

                                                ORDER

          (As per Sri C. V. Rao, Honourable Male Member, on behalf of the Bench)

 

1.       The Complainant asked the Forum to pass order in his favour and against the Opposite Party as follows: i) to pay Rs.6,200/- (Rupees six thousand and two hundred only) with interest from the date of repudiation, ii) to pay damages of Rs.50,000/- for deficiency in service, iii) Costs and iv) For such other relief or reliefs as the Forum deems fit and proper in the circumstances of the case.

2.     The Opposite Party strongly resisted the claim of the Complainant and asked the Forum to dismiss the complaint with costs. 

         

 3.      The case of the Complainant, as can be seen from the Complaint, is that the Complainant is working with the HPCL with employee No.35416900 and the HPCL had a tie up with the Opposite Party for settling the medical claims of the employees of HPCL.  The tie up was governed by the Health Insurance Scheme Policy No.130500/46/05/2100000193 as per the agreement entered between the Management of HPCL, Mumbai and the Opposite Party Tardeo Branch, Mumbai and was renewed every year on 1^st January.   The insurance policy is valid up to 31.12.2007 only.   The Complainant stated that the Complainant’s wife A.S.S.M. Lakshmi, when suffering with problems relating to stiffness right shoulder & right hip and obesity, the Complainant’s wife and the Complainant approached Dr. N. Siva Prakash, MD General Medicine, Asst. Professor, King George Hospital, for treatment Dr. Siva Prakash, MD advised the Complainant’s wife to attend physiotherapy regarding stiffness right shoulder & right hip and obesity, which will be seen from a copy of prescription.   The Complainant stated that accordingly the Complainant’s wife had approached M/s. Patanjali Yoga Kendra, 6-11, MVP Colony, Visakhapatnam, which is nearer to the Complainant’s house.   The Complainant’s wife aged 32 years was suffering from Bronchial Asthma since childhood, Arthritis, Thyroid and Gastric Problem, knee joint pains, overweight in addition to stiffness right shoulder & right hip and obesity.   The Complainant’s wife underwent Physiotheraphy in the Patanjali Yoga Kendra for a period of 2 months from 01.06.2007 to 31.07.2007.   The Complainant came to know that while the treatment was given necessary entries have been made in the register of M/s. Patanjali Yoga Kendra.   The Complainant’s wife had paid Rs.6,100/- to M/s. Patanjali Yoga  Kendra.   As the treatment is continued the Complainant’s wife paid an amount of Rs.6,100/- in two installments comprising of Rs.3,000/- and Rs.3,100/-.     After the treatment completed when the Complainant have to prefer the claim for reimbursement of the expenditure incurred on the treatment of the Complainant’s wife, he approached M/s. Patanjali Yoga Kendra, M.V.P. Colony.   The Complainant has been given two cash receipt Nos. 86 & 87 for Rs.3,000/- and Rs.3,000/-    The Complainant came to know that the receipts were given under the name of M/s Swamy Vivekanada Nature Cure Hospital & Yogashram .   Basing on the receipts given by M/s Swamy Vivekananda Nature Cure Hospital & Yogashram, the Complainant applied for medical reimbursement to the Opposite Party through HPCL, Visakha Regional Office, opposite to A.U. Ingate, Visakhapatnam for Rs.6,200/- including Rs.100/- consultation fee of Dr. N. Siva Prakash, MD.   The Complainant stated that the Complainant was astonished to note that the Opposite Party addressed to Chief Regional Manager Retail, HPCL, Visakha Retail Regional Office, Visakhapatnam that based on the Surveyor of the Opposite Party’s report that the Complainant’s wife had not taken any treatment or massage from M/s. Swamy Vivekananda Nature Cure Hospital and Yogashram and the bills submitted are fake and bogus.   Basing on the letter of the Opposite Party dated 21.09.2007, the Complainant received a direct letter dated 23.11.2007 from HPCL, Visakhapatnam served on 29.11.2007 that the treatment of the Complainant’s wife are bogus and fake and that the claim is not genuine.   Further the Complainant and his family members were debarred from claiming medical benefits Insurance Plan for a period of 2 years.   The Complainant further stated that unilaterally without giving an opportunity to plead the case of the Complainant, on the basis of the Opposite Party’s letter, the receipts for Rs.3,000/- and Rs.3,100/- along with claim preferred by the Complainant for Rs.6,200/- were considered fraudulent and the Complainant and the family members are debarred from future claims for a period of 2 years with effect from 29.11.2007.   The Opposite Party did not care to follow the prescribed procedure in vogue and also failed to follow the terms and conditions of the policy.   Thereupon the Complainant made several appeals to HPCL as well as to the Opposite Party and finally approached the Ombudsman for amicable solution as there is no fraudulent claim at all.   The Ombudsman while dismissing the complaint observed that the Opposite Party should review the claim.   But the Opposite Party has not cared and closed the matter without payment of Rs.6,200/-.   Hence, this Complaint.

 

4.       The Complainant filed an affidavit, besides written arguments to support his claim.   Exs.A1 to A35 are marked for the Complainant.

 

5.       On the other hand, the Opposite Party resisted the claim of the Complainant by contending, as can be seen from its counter, that as per the records of the Opposite Party, the HPCL authorities have taken the insurance policy from the Opposite Party.   In order to protect the interest of the employees, the Opposite Party issued the medi-claim policy to the HPCL organization in order to cover the health risks, the policy valid up to 31.12.2007.    The said policy was issued with certain terms, conditions and exclusions.    In case of the violation of said terms and conditions which amounts to breach of conditions of the policy, thereby the Opposite Party is not at all liable to indemnify the policy holder.   The Opposite Party stated that the Opposite Party received the claim intimation from the HPCL authorities alleging that the wife of the Complainant was suffering with stiffness of right shoulder, hip and obesity etc.  The Complainant allegedly incurred an amount of Rs.6,200/- towards the alleged treatment in the alleged hospital.   The Opposite Party stated that after receipt of the said information, the Opposite Party appointed the surveyor in order to ascertain true state of affairs, the surveyor after conducting the detailed survey submitted the report, the survey report reveals that the bills submitted by the Complainant are fake, no treatment was taken by wife of the Complainant as alleged by the Complainant.  The Opposite Party, based on the survey report, as per the policy conditions, repudiated the claim of the Complainant, the said fact was informed to the HPCL authorities in writing.   The Opposite Party stated that as the Opposite Party repudiated the claim of the Complainant, the HPCL Authorities also taken the decision by following their internal procedure debarring the Complainant to claim the medical facilities as a employee of the HPCL, in future for a period of two years.   The Complainant approached the Insurance Ombudsman, the authority also pleased to dismiss the complaint of the Complainant on 20.08.2009 asking   the Opposite Party to review on the admissibility of the claim of the Complainant, if the Complainant submits a copy of orders of the HPCL authorities absolving him of any wrong doing with respect of the receipts.  As stated supra the HPCL authorities also observed that the bills submitted by the Complainant are fake.  Accordingly, the authorities issued the proceedings debarring the Complainant to claim medi-claim facilities for a period of two years.   The Opposite Party further stated that there is no cause of action to file the present case against the Opposite Party and also non-compliance of the orders of the insurance ombudsman and filing the Complainant for claim amounts is premature and thereby the Complainant’s claim is liable to be dismissed in limine.

6.       The Opposite Party filed an affidavit, besides written arguments, to buttress its contentions.   Ex.B1 to B8 are marked for the Opposite Party.

 

7.       The matter has been heard on behalf of the Complainant as well as the Opposite Party.

 

8.       After careful perusal of the case record, this Forum finds that after detailed investigation by its surveyors, more than once, the Opposite Party repudiated the claim of the Complainant.   Moreover, after receiving the detailed report and other corollary documents, HPCL, the employer of the Complainant, debarred the Complainant to claim medi-claim facilities for a period of 2 years.   Thereupon the Complainant approached the Insurance Ombudsman against this Opposite Party, the insurer New India Assurance Company Ltd., asking for relief against the repudiation of his claim under Group Medical Policy GMP taken by HPCL covering their employees of whom, he was one.   As can be seen from Ex.A21, order of the Insurance Ombudsman, it clearly said “we direct the insurers do another review on the admissibility of the claim of Rs.6,200/- in case the Petitioner submits a copy of the decision of HPCL’s authorities absolving him of any wrong doing with respect to the receipts”.   But though the Complainant resorted to huge correspondence with the HPCL authorities, to date the said authorities did not absolve him of wrong doing with respect to the receipts submitted by him for his claim of Insurance.   Moreover, very peculiarly he did not make his employer, namely HPCL, as a party in this complaint.   It is commonsense that unless and until his employer, namely HPCL, absolves him of any wrong doing with respect of the allegedly taken bogus receipts, the Complainant has no leg to stand on for his rights as the insured.   The Complainant has approached this Forum without clearing his record with his employer-who is the facilitator of the insurance and so for all practical purposes, has approached this Forum with unclean hands holding an untenable claim.   As such, this Complaint is liable to be dismissed.  

 

 

 

 

 

9.       In the result, this Complaint is dismissed.   No costs.

     Dictated to the Steno, transcribed by him, corrected and pronounced by us in the Open Forum, this the 9^th  day of December, 2014.

Sd/-                                         Sd/-                                         Sd/-  

President                            Lady Member                             Male Member

                             APPENDIX OF EVIDENCE

For the Complainant:-

NO.	DATE	DESCRIPTIONOFTHEDOCUMENTS	REMARKS
Ex.A01	10.04.2007	Dr. Siva Prakash Prescription	Original
Ex.A02	10.04.2007	Receipt for Rs.100/-	Photo copy
Ex.A03	20.04.2007	Case Sheet Dr GNB Prasad	Photo cop
Ex.A04	20.06.2007	Receipt No.86 for amount of Rs.3,000/-in favour of Complainant	Attested photo copy
Ex.A05	31.07.2007	Receipt No.87 for amount of Rs.3,100/-	Attested photo copy
Ex.A06	31.07.2007	Medical Bill issued by Hospital Authorities.	Attested Photo copy
Ex.A07	02.10.2007	Letter issued by Patanjali Yoga Kendra Dr. of G.N.B. Prasad	Original
Ex.A08	03.10.2007	Letter issued by Complainant to The Dy. Manager-HR, HPCL	Photo copy
Ex.A09	23.11.2007	Letter issued by Chief Regional Manager-DS, HPCL to Complainant	Original
Ex.A10	26.11.2007	Letter issued by Complainant to Dy. Manager-HR Visakha RO	Office copy
Ex.A11	27.11.2007	Vigilance Clearance Certificate	Office copy
Ex.A12	12.12.2007	Letter sent by Complainant to the General Manager (HR) Mktg. HPCL, Mumbai.	Office copy
Ex.A13	18.12.2007	Affidavit of G. Veda Bhaskaram	Office copy
Ex.A14	08.01.2008	Letter issued by Complainant to G. Veda Bhaskaram, Patanjali Yoga Kendra, Vsp.	Office copy
Ex.A15	22.01.2008	Letter issued by Veda Bhaskaram to Complainant	Orginal
Ex.A16	23.01.2008	Postal Acknowledgements (2)	Photo copy
Ex.A17	15.10.2008	Letter issued by Complainant to Sri Pushp Joshi, General Manager, HPCL, Mumbai.	Office copy
Ex.A18	11.12.2008	Letter issued by G.N.B. Prasad, Swamy Vivekananda Nature Cure Hospital & Yogashram to OP.	Original
Ex.A19	23.01.2009	Letter issued by G.N.B. Prasad, Swamy Vivekananda Nature Cure Hospital & Yogashram to OP.	Original
Ex.A20	06.05.2009	Letter issued by HPCL to Complainant	Office copy
Ex.A21	10.06.2009	Letter issued by V. Vijay Kumar, Proprietor of Waltair Medicals to OP	Office copy
Ex.A22	20.08.2009	Order of the Insurance Ombudsman, Hyderabad	Photo copy
Ex.A23	09.09.2009	Identity Certificate	Original
Ex.A24	09.10.2009	Letter issued by Complainant to OP	Original
Ex.A25	27.10.2009	Letter issued by OP to Complainant.	Original
Ex.A26	17.12.2009	Letter issued by Complainant to HPCL	Photo copy
Ex.A27	02.01.2010	Letter issued by OP to Complainant	Office copy
Ex.A28	18.01.2010	Letter issued by Complainant to OP	Photo copy
Ex.A29	21.01.2010	Letter issued by OP to Complainant	Office copy
Ex.A30	09.03.2010	Letter issued by Complainant to Chief Regional Manager-DS, HPCL	Photo copy
Ex.A31	21.01.2011	Doctor prescription to A.S.S.M. Lakshmi	Original
ExA32	19.09.2011	Certificate issued by Dr. Reeta Prasad Nair	Original
Ex.A33	17.09.2007	Voucher made by OP to HPCL	Office copy
Ex.A34	01.10.2007	Cheque issued by HPCL for 5 claims,	Photo copy
Ex.A35	15.05.2009	Certificate of Dr. N. Siva Prakash	Photo copy

For the Opposite Party:-                                    

NO.	DATE	DESCRIPTIONOFTHEDOCUMENTS	REMARKS
Ex.B01	08.10.2008	Policy wording given to the insured-HPCL.	Attested copies
Ex.B02	18.11.2008	Letter received from Mumbai Office to OP	Attested copy
Ex.B03	04.09.2008	Letter addressed to Mumbai office	Attested copy
Ex.B04	22.01.2009	Letter addressed to Mumbai Office by OP	Attested copy
Ex.B05	28.01.2009	Letter received from Mumbai Office	Attested copy
Ex.B6	21.09.2007	Surveyor Report	Attested copy
Ex.B7	12.01.2009	Surveyor Report	Attested copy
Ex.B8	13.08.2009	Letter addressed to Insurance Ombudsman	Attested copy

 Sd/-                                        Sd/-                                         Sd/-            

President                        Lady Member                                   Male Member