Andhra Pradesh

Chittoor-II at triputi

CC/28/2019

K.Ramesh Babu, S/o Late K.Ramachandra Naidu, aged 67 years. - Complainant(s)

Versus

M/S United India Insurance Co. Ltd., Rep. by its Senior Divisional Manager - Opp.Party(s)

Y.Venkateswara Rao

13 Sep 2019

ORDER

 

 

                                                                                                                                              Filing Date: 20-02-2019                                                                                                                                                                                      Order Date: 13-09-2019

 

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-II, CHITTOOR AT TIRUPATI.

Present: - Sri.T.Anand, President (FAC)

                                                                                                 Smt.T.Anitha, Member

 

 FRIDAY THE THIRTEENTH DAY OF SEPTEMBER, TWO THOUSAND AND NINETEEN

 

C.C.No.28/2019

Between

K. Ramesh Babu, S/o. Late K. Ramachandra Naidu,

Aged about 67 years, Advocate, residing at Sri Sai Nilayam,

D.No. 18-38, S-2-73, (Old D.No. 18-1-17A),

Madhura Nagar, Tirupati.                                                                       … Complainant

 

And

 

1. M/s. United India Insurance Co. Ltd.,

Rep. by its Senior Divisional Manager,

Divisional Office, 7 & 8, Sridevi Complex,

Tilak Road, Tirupati, Chittoor District.

 

2. The Health India TPA Services Pvt. Ltd.,

 H.No. 7-1-28/9A,

 1^st Floor, Sai Towers,

 Opp. Lane of Indo US Hospital,

 Near Lal Bungalow,

            D.K. Road, Ameerpet,

            Hyderabad, Telangana – 500 016.                                            … Opposite parties

 

        This complaint coming on before us for final hearing on 29.08.2019 and upon perusing the complaint and other relevant material papers on record and on hearing of Sri.Y.Venkateswara Rao, counsel for the complainant, and Sri. Gotti Gajendra, counsel for the opposite party No.1 and opposite party No.2 is remained exparte having stood over till this day and for consideration, the Forum made the following.

ORDER

DELIVERED BY SMT. T. ANITHA, MEMBER

ON BEHALF OF THE BENCH

        This complaint is filed by the complainant under section 12 of the Consumer Protection Act 1986, complaining the deficiency in service on part of the opposite parties and prayed this Forum to direct the opposite parties to pay an amount of Rs. 75,044/- towards claim with interest @ 24% p.a. from the date of the claim till realization and to pay Rs. 1,00,000/- towards compensation for mental agony suffered by the complainant due to deficiency in service on part of the opposite parties and to pay costs of the complaint.

        2. The brief facts of the case are:  The complainant has taken a policy from the first opposite party through the second opposite party, under the scheme “Hospitalisation and Domicilary Hospitalisation Benefit Policy” vide policy No. 0512812818P103604275 for himself and his wife Smt. Shakila Ramesh Babu and daughter K.Anisha and the coverage starts from 16.06.2018 to 15.06.2019. The complainant further submits that, his wife Smt. Shakila Ramesh Babu was admitted in Indigo Womens Centre Hospital on 14.07.2018 as inpatient and took treatment for ‘Peri menopausal abnormal uterine bleeding’ and  was discharged on 15.07.2018 and he spent Rs.75,044/- for her treatment. Accordingly the complainant has submitted the claim to the opposite party No.1 through opposite party No.2 vide No.CCN HI LIC 000558298 and the said claim was received by the opposite party No.1 on 03.10.2018 and failed to settle the claim. Hence the complainant caused a legal notice on 29.12.2018 to the opposite parties requesting them to settle the claim. The said notice was received by the first opposite party and reply was given on 08.01.2019 stating that the claim is not payable as per policy conditions and exclusions. The complainant further submits that, he has complied all the above conditions while taking the treatment for his wife and hence he is entitled to the claim for medical expenses incurred by him. But the opposite parties failed to consider his claim which is nothing but deficiency in service on part of the opposite party No.1. Hence he filed the present complaint.

        3.  After receipt of the notices issued by this forum, the opposite party No.2 failed to attend before this forum. Hence he was called absent and set exparte on 24.04.2018.

       4.  The opposite party No.1 filed the written version by admitting the policy of the complainant and denied the allegations made by the complainant in his complaint and further submits that as per the policy, there are certain exclusions to the effect that the company shall not liable to make any payment under the policy in respect of expenses whatsoever incurred by any insured person in connection with or in respect of clause “4.9 that Convalescence, general debility, run-down condition or rest cure, obesity treatment and its complications including morbid obesity, Congenital external disease or defects or anomalies, treatment relating to all psychiatric and psychomatic disorders.  Infertility, Sterility, Veneral disease, intentional self injury and use of intoxication drugs/alcohol”, “4.11 that charges incurred at Hospital or Nursing Home primarily for diagnosis, X-Ray or Laboratory examinations or other diagnostic studies not consistent with or incidental to the diagnosis and treatment of positive existence or presence of any ailment, sickness or injury, for which confinement is required at Hospital/Nursing Home”.

        5.  The opposite party further submits that the second opposite party sent a letter to them on 16.10.2018 with regard to the complainant’s claim, after scrutiny of the documents, by noting that, the claimant Mrs. K.Shakila was admitted in Indigo Womens Centre, Chennai from 14.07.2018 to 15.07.2018. During her stay, the claimant underwent diagnostic hysteroscopy. However diagnostic procedures are not payable under the policy. Also the claimant underwent Mirena insertion which is related to preventions of conception. This is also not payable under the policy conditions as per clause 4.9. Hence as per the terms and conditions of general mediclaim-UIIC, this claim stood repudiated. Hence the complainant is not entitled to any claim as stated in the complaint as there is no deficiency in service on part of them and the complaint is liable to be dismissed.

        6. The complainant filed his evidence on affidavit and Ex: A1 to A9 were marked. On behalf of the opposite party No.1 one R. Varalakshmi, W/o. R.Ravindranath, Senior Divisional Manager, United India Insurance Company Limited filed her chief affidavit and Ex:B1 and B2 were marked. Both parties filed their written arguments and submitted oral arguments.

        7. Now the point for consideration is:-

        Whether there is any deficiency in service on part of the opposite parties? If so, to what extent, the complainant is entitled for the reliefs sought for?

                   8.Point:-  The main case of the complainant is, he took policy from the opposite party No.1 through opposite party No.2 under the scheme of “Hospitalisation and Domicilary Hospitalisation Benefit Policy” vide policy No. 0512812818P103604275 in the name of himself, his wife Smt. K.Shakila Ramesh Babu and  for his daughter  and paid the premium and the policy period starts from 16.06.2018 to 15.06.2019. The complainant further submits that, he admitted his wife Mrs.K.Shakila Ramesh Babu in Indigo Womens Hospital on 14.07.2018 as inpatient for the treatment of Peri menopausal abnormal uterine bleeding and discharged on 15.07.2018 and he spent Rs.75,044/- for her treatment and accordingly he submitted a claim to the opposite party No.1 through opposite party No.2 and same was received by opposite party No.1 on 03.10.2018 but they failed to settle the claim. Hence the complainant issued legal notice dt: 29.12.2018 under Ex:A7 to the opposite parties and the same was received by them and reply was given to the notice on 08.01.2019 under Ex:A9 by repudiating the claim of the complainant ,which is nothing but deficiency in service on part of the opposite parties .

                     The complainant, in order to support his case, got marked Ex:A1 policy copy and  Ex:A2 discharge summary which show that,  his wife took treatment in indigo women’s hospital during the period from 14.07.2018 to 15.07.2018 and also got marked Ex:A4       bunch of bills showing the expenditure incurred for the treatment, Ex:A5 claim form dated 03.10.2018,  and Ex:A9 repudiation letter issued by opposite parties to the complainant dated 08.09.2018. In the repudiation letter they have stated that, the  claim will not cover the nature of  treatment taken by the wife of the complainant as the said procedure i.e hysteroscopy diagnostic procedure which is not covered as per policy exclusion clause No.4.9 and Mirena insertion, which is related to prevention of conception also not payable as per clause 4.9 of the policy.

                     9. The counsel for the complainant further invited our attention to clause 3.19 relating to “In-Patient Care” which reads as follows:- In-Patient care means treatment for which the insured person has to stay in a hospital for more than 24 hours for a covered event.

                         In this particular case also the complainant got admitted his wife on 14.07.2018 for the treatment of Perimenopausal abnormal uterine bleeding and after taking the treatment she was discharged on 15.07.2018 hence he will come under the clause 3.19 as his wife stayed for 24 hours in the hospital for the treatment hence, clause 3.19 is applicable in this case.

         10. The counsel for the complainant further stated that after receiving the premium, the opposite parties in order to escape from their liability, have repudiated the claim without any reasonable ground and it is nothing but unfair trade practice and deficiency in service on part of them.

      The counsel for the opposite parties stated that they have accepted the policy of the complainant, his wife and daughter and same was valid from 16.06.2018 to 15.06.2019 and further stated that as per the policy, there are certain conditions and exclusions under which the company shall not be liable to make any payment under the policy in respect of expenses whatsoever incurred by any insured in connection with or in respect of clause“4.9 that Convalescence, general debility, run-down condition or rest cure, obesity treatment and its complications including morbid obesity, Congenital external disease or defects or anomalies, treatment relating to all psychiatric and psychomatic disorders.  Infertility, Sterility, Veneral disease, intentional self injurty and use of intoxication drugs/alcohol”. As per clause 4.11, her charges incurred at Hospital or Nursing Home primarily for diagnosis, X-Ray or Laboratory examinations or other diagnostic studies not consistent with or incidental to the diagnosis and treatment of positive existence or presence of any ailment, sickness or injury, for which confinement is required at Hospital/Nursing Home”. The counsel further stated that the insured Smt.K.Shakila was admitted at Indigo Womens Centre, Chennai from 14.07.2018 to 15.07.2018. During her stay, she underwent diagnostic hysteroscopy. As per the clause 4.9 and 4.11 of the policy, diagnostic procedures are not payable, further she underwent Mirena Insertion which is related to prevention of conception. Therefore she is not entitled for the claim from this opposite party as per clause 4.9. Hence as per the terms and conditions of general mediclaim, this claim stands repudiated hence there is no deficiency in service on part of them because as per the terms and conditions of the policy.

         11.  The counsel for the opposite party got marked Ex:B1 the policy copy No. 0512812818P103604275 of the complainant which is valid from 16.06.2018 to 15.06.2019. In order to show that they gave reply to the complainant for repudiating her claim through letter and same is marked as Ex:B2 dt: 16.10.2018.

                  After perusing the evidence placed by both the parties there is no dispute regarding the policy taken by the complainant for himself, his wife Smt.K.Shakila Ramesh Babu and his daughter K.Anisha, and same was admitted by the opposite parties. The main case of the complainant is, his wife suffered with abnormal uterine bleeding and hence he went to Indigo Womens Hospital, Chennai for the treatment of Perimenopausal abnormal uterine bleeding and as per the medical advice he got admitted his wife as inpatient on 14.07.2018 and she was discharged on 15.07.2018. During her admission in the hospital she had undergone Mirena insertion procedural treatment for controlling abnormal uterine bleeding and in order to prove that the complainant filed Ex:A2 discharged summary issued by Indigo Womens Hospital, Chennai, in which it is clearly mentioned that in the course of treatment she has under gone tests for the diagnostic hysteroscopy followed by Mirena coil insertion. She was taken up to the operation theatre for the treatment after taking consent and pre-anesthatic evaluation was done which clearly show that the procedure of treatment is not a diagnostic procedure. To some extent it is surgical procedure.

 

                                12.  The counsel for the opposite party stated that, the complainant is not liable for the claim amount, as  the treatment which she has taken will come under the exclusion clause i.e. 4.9 and 4.11 of terms and conditions of the policy under Ex:B1. Clause 4.9 reads as follows:-  Convalescence, general debility, run-down condition or rest cure, obesity treatment and its complications including morbid obesity, Congenital external disease or defects or anomalies, treatment relating to all psychiatric and psychomatic disorders.  Infertility, Sterility, Veneral disease, intentional self injurty and use of intoxication drugs/alcohol”, Clause 4.11 reads as follows:- charges incurred at Hospital or Nursing Home primarily for diagnosis, X-Ray or Laboratory examinations or other diagnostic studies not consistent with or incidental to the diagnosis and treatment of positive existence or presence of any ailment, sickness or injury, for which confinement is required at Hospital/Nursing Home”. But nowhere, it was mentioned in the policy copy under Ex:A2 and Ex:B1that hysteroscopy and Mirena insertion procedure are excluded. Hence in this particular case, exclusions mentioned by the counsel for the opposite party i.e. 4.9 and 4.11 are not applicable in the present case. Hence the contention of the opposite parties will not be considered. In order to escape from the liability, the opposite parties 1 and 2 relied upon the clause 4.9 and 4.11. But it is held that there is deficiency in service and unfair trade practice on part of opposite parties for the above mentioned reasons. Hence we are of the opinion that there is clear deficiency in service on part of opposite parties towards the complainant. Hence this point is answered in favour of the complainant.

                                13. The complainant stated that, he has incurred Rs.75,044/- towards the treatment for his wife and paid the same in Indigo Womens Hospital. But as per Ex:A4 the bunch of bills shows that, the complainant has paid an amount of Rs. 44,300/- only after getting discount of Rs.27,244/-. Hence the complainant is entitle for Rs.44,300/- with interest @ 9% p.a. from the date of the pre repudiation letter issued by the opposite parties 1 and 2 under Ex:B2 dt: 16.10.2018 till realization. The complainant is further entitle an amount of Rs.5,000/- towards compensation for mental agony  and deficiency in service  on part of the opposite parties and also the complainant is  further entitled an amount of Rs.3,000/- towards litigation expenses.

                    14. In the result, the complaint is allowed in part directing the opposite parties 1 and 2 jointly and severally to pay an amount of Rs. 44,300/- (Rupees forty four thousand three hundred only) with interest @ 9% p.a. from the date of pre-repudiation letter dt: 16.10.2019 under Ex:B2 till realization. The opposite parties 1 and 2 are further directed to pay an amount of Rs. 5,000/- (Rupees five thousand only) towards compensation for mental agony suffered by the complainant due to deficiency in service on part of the opposite parties. The opposite parties 1 and 2 are further directed to pay an amount of  Rs. 3,000/- (Rupees three thousand only) towards legal expenses. The opposite parties     1 and 2 are further directed to comply with the order within six (6) weeks from the date of receipt of copy of this order failing which, the above said compensation amount of Rs. 5,000/- (Rupees five thousand only) shall also carry interest @ 9% p.a. from the date of this order till realization.

        Dictated to the stenographer, transcribed and typed by her, corrected and pronounced by me in the Open Forum this the 13^th day of September, 2019.

            Sd/-                                                                                                         Sd/-                                                           

    Lady Member                                                                                                 President (FAC)

 

APPENDIX OF EVIDENCE

 

Witnesses Examined on behalf of Complainant/s.

 

PW-1: Sri K. Ramesh Babu (Chief affidavit filed).

 

Witnesses Examined on behalf of Opposite PartY/S.

 

RW-1: Smt R. Varalakshmi  (Chief affidavit filed).

 

 

EXHIBITS MARKED ON BEHALF OF THE COMPLAINANT/s

 

Exhibits (Ex.A)	Description of Documents
	Original copy of INDIVIDUAL HEALTH POLICY SCHEDULE vide Policy No. 0512812818P103604275, Period of Insurance from 16.06.2018 to 15.06.2019 issued by United India Insurance Company Limited, Tiruchanoor Road, Chittoor -517 501 Andhra Pradesh.
	Photo copy of DISCHARGE SUMMARY in the name of Mrs. Shakila Ramesh Babu issued by INDIGO WOMENS CENTER, Anna Nagar, Chennai. Dt: 15.07.2018.
	Photo copy of 2 Advance Receipts issued by the INDIGO WOMENS CENTER, Anna Nagar, Chennai. Dt: 14.07.2018.
	Photo copy of Bunch of Bills cum Receipts issued by the INDIGO WOMENS CENTER, Anna Nagar, Chennai.
	Photo copy of HOSPITALISATION AND DOMICILARY HOSPITALISATION BENEFIT POLICY CLAIM FORM submitted by the claimant to the opposite party No.1.
	Letter addressed by the 1st opposite party to 2nd opposite party rejecting the claim of the complainant. Dt: 12.09.2018.
	Office copy of the LEGAL NOTICE issued to the opposite parties by the complainant. Dt: 29.12.2018.
	Postal Acknowledgement of the opposite party No.1.
	Original copy of Letter addressed by the 1st opposite party rejecting the claim of the complainant. Dt: 08.01.2019.

 

EXHIBITS MARKED ON BEHALF OF THE OPPOSITE PARTY/s

 

Exhibits (Ex.B)	Description of Documents
	Certified true copy of Individual Health Policy Schedule vide Policy No. 0512812818P103604275, Period of Insurance from 16.06.2018 to 15.06.2019 issued by United India Insurance Company Limited, Tiruchanoor Road, Chittoor -517 501 Andhra Pradesh.
	Served copy of PRE REPUDIATION LETTER to opposite party No.1 by opposite party No.2. Dt: 16.10.2018.

 

 

                                                                                                                                                            Sd/-

                                                                                                   President (FAC)

 

// TRUE COPY //

// BY ORDER //

 

 

Head Clerk/Sheristadar,

            Dist. Consumer Forum-II, Tirupati.

 

Copies to:  1) The Complainant, 

                  2) The Opposite parties 1 and 2.