Date of filing:4.4.2014
Date of Disposal:23.9.2014
BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-II::
VIJAYAWADA, KRISHNA DISTRICT.
Present: SMT N. TRIPURA SUNDARI, B. COM., B. L., PRESIDENT (FAC)
SRI S.SREERAM, B.COM., B.A., B.L., MEMBER
TUESDAY, THE 23rd DAY OF SEPTEMBER, 2014.
C.C.No.77 OF 2014
Between :
Dr.K.Kishore Babu, S/o K.Sriramulu (Late), Hindu, Profession, R/o Boyapati Madhavarao Street, Mogalrajpuram, Vijayawada – 10, Vijayawada DMC.
….. Complainant.
And
1. M/s Vidal Health (3rd party administrator), Formerly known as TTK Healthcare TPA Pvt., Ltd., Rep., by its Officer Incharge/Vice President-Technical, 47-14-1, 4th Floor, Vidisha Towers, Dwaraka Nagar Main Road, Visakhapatnam – 530 016.
2. M/s United India Insurance Company Ltd., Rep., by its Divisional Manager, Divisional Office – II, Upstairs of Andhra Bank, M.G.Road, Patamata, Vijayawada.
…....Opposite Parties.
This complaint is coming before us for final hearing on 8.9.2014 in the presence of Sri C.Sreepathi Rao, Advocate for complainant and Sri T.Veerabhadra Rao, Advocate for opposite parties and upon perusing the material available on record, this Forum delivers the following:
O R D E R
(Delivered by Hon’ble President (FAC) Smt N. Tripura Sundari)
This complaint is filed under Section 12 of the Consumer Protection Act, 1986.
The averments of the complaint are in brief:
1. The complainant obtained a mediclaim policy from the 2nd opposite party in the year 2002 and it was renewed regularly. The present policy covers the period from 27.2.2013 to 26.2.2014 for a sum of Rs.3,50,000/- . Besides this policy the complainant also obtained another medicalim policy from Oriental Insurance Company covering the period from 8.12.2012 to 7.12.2013 for a sum of Rs.3,00,000/-. While the matter stood thus the complainant was admitted in Aayush Hospital, Vijayawada on 1.8.2013 for the purpose of right total knee replacement and discharged on 16.8.2013. The hospital authorities issued a bill for Rs.6,01,228/- towards entire medical expenditure. The complainant informed about his joining and treatment in the hospital. After completion of the treatment the complainant submitted claim form along with necessary documents. On receiving the claim form the 1st opposite party who is third party administrator of claims on behalf of the 2nd opposite party appointed another investigator and he verified the hospital records and found that the claim of the complainant is genuine. The Oriental Insurance Company settle the claim of the complainant within ten days as per the terms and conditions of the policy. But surprisingly the 1st opposite party sent a claim settlement letter in the month of December, 2013 disclosing that they have agreed to pay 70% on the sum assured of Rs.3,00,000/- i.e., an amount of Rs.2,10,000/- without arising any reasons. That the complainant obtained policy for Rs.3,50,000/-. In such circumstances the complainant sent a letter dated 13.12.2013 to the opposite parties with a request to reconsider his claim and pay the balance amount on the sum assured of Rs.3,50,000/-. On receipt of the said letter the 1st opposite party sent a letter dated 8.1.2014 by mentioning different clauses of the policy which are not applicable for the complainant’s case and even as per those conditions also the 1st opposite party has no right to settle the claim for Rs.2,10,000/- including clause No.4.3 of the policy. Whereas the complainant is a policy holder from 2002 onwards the question of pre-existing disease does not arise. The 1st opposite party created to escape from their liability. Therefore the complainant got issued a legal notice demanding the opposite parties to pay the balance amount of Rs.35,000/- together with interest at 24% per annum from the date of claim till payment. The 1st opposite party issued reply by repeating their previous version without considering the object and spirit of insurance under mediclaim policy. It is nothing but deficiency of service and caused lot of mental agony to the complainant. Hence the complainant is constrained to file this complaint against the opposite parties praying the Forum to direct the opposite parties to repay Rs.35,000/- together with interest at 24% per annum from the date of claim i.e., 20.8.2013 till the date of payment, to pay Rs.25,000/- towards compensation for mental agony and to pay costs.
2. The 2nd opposite party filed its version and the 1st opposite party adopted the same.
The version of the opposite parties is in brief:
The opposite parties denied all the allegations of the complaint and submitted that under four exclusions the opposite parties’ insurance company shall not be liable to make anything under this policy for any expenses in respect of condition No.4.1. Any pre-existing condition (s) as defined in the policy until 48 months of continuous coverage of such insured person have elapsed since inception of his/her first policy with the company. Condition No.4.2 Any disease other than those stated in Clause No.4.3 and 4.4 contracted by the insured person during the first 30 days from the commencement of date of policy the exclusion shall not however apply in case of the insured person having been covered under insurance scheme with the company for a continuous period of preceding 12 months without any break. Condition No.4.3 During the first two years of the operation of the policy the expenses on treatment of diseases such as cataract, benign prostatic hypertrophy, hysterectomy for menorrhagla or fibromyoma, hemia, hydrocele, congenital internal disease, fistula in anus, piles, sinusitis and related disorders, gall bladder stone removal, gout & rheumatism, calculus diseases are not payable. Condition No.4.4. During the first four years of the operation of the policy the expenses related to treatment of joint replacement due to degenerative condition and age-related osteoarthritis & osteoporosis are not payable. If these diseases mentioned in Exclusion No.4.3 and 4.4 (other than congenital internal disease) or pre-existing at the time of proposal they will not be covered even during subsequent period of renewal subject to the pre-existing disease exclusion clause. If the insured is aware of the existence of congenital internal disease before inception of policy the same will be treated as pre-existing. The 2nd opposite party wrote a letter to the complainant explaining that sum insured has been enhanced from Rs.3,00,000/- to Rs.3,25,000/- during last year and Rs.3,50,000/- during the current policy year and that if the policy is renewed for enhanced sum insured, then the restrictions are applicable to fresh policy (condition 4.1, 4.2 and 4.3) will apply to additional sum insured as if a separate policy has been issued for the difference and that he would agree the enhanced sum insured has not completed the waiting period of four years to be considered for settlement under policy Clause No.4.3 Rs.3,00,000/- only qualifies to be considered as this limit has completed the necessary waiting period under the said clause and that in view of the 2nd opposite party insurance company have considered 70% of the applicable sum insured of Rs.3,00,000/- in accordance with the policy provisions and settled the claim of Rs.2,10,000/- and further it is observed from the discharge summary that the complainant underwent left total knee replacement in 2011 and the sum insured is increased from Rs.3,00,000/- to Rs.3,25,000/- from 27.2.2012 and to Rs.3,50,000/- with effect from 27.2.2013. Hence the ailment is pre-existing to the increased sum insured. The opposite parties already settle the claim. Therefore there is no deficiency in service on the part of the opposite parties and prayed to dismiss the complaint with costs.
3. On behalf of the complainant he filed his affidavit and got marked Ex.A.1 to Ex.A.12 and on behalf of the 2nd opposite party Sri V.Sunil Kumar, Deputy Manager filed his affidavit and marked Ex.B.1.
4. Heard and perused.
5. Now the points that arise for consideration in this complaint are:
1. Whether there is any deficiency in service on the part of the opposite parties
towards the complainant in not accepting the claim for full payment?
2. If so is the complainant entitled for any relief?
3. To what relief the complainant is entitled?
POINTS 1 AND 2:-
6. On perusing the material on hand the complainant obtained mediclaim policy from the 2nd opposite party in the year 2002 under Ex.A.1 and it was renewed regularly. The present policy Ex.A.2 covers the period from 27.2.2013 to 26.2.2014 for a sum of Rs.3,50,000/-. The complainant was admitted in Aayush Hospital, Vijayawada on 1.8.2013 for his right knee replacement and after surgery the hospital authorities issued a bill for Rs.6,01,228/- under Ex.A.3. After completion of treatment the complainant submitted claim form along with necessary documents and on receiving the same the opposite parties sent Ex.A.4 dated 27.8.2013 stating “required original documents”. The complainant sent a letter Ex.A.5 dated 31.8.2013 stating that he is forwarding all necessary original documents related to his right knee replacement surgery. On receiving another letter from opposite parties the complainant sent a letter dated 13.12.2013 Ex.A.6 stating that the complainant insured amount of the policy is Rs.3,50,000/- and the amount claimed for the above was Rs.3,00,000/- but the opposite parties have settled the claim by paying Rs.2,10,000/- by deducting Rs.90,000/- with remarks of 70% of sum insured and requested the opposite parties to verify and settle the balance amount. On receipt of the said letter the 1st opposite party sent a letter Ex.A.7 dated 8.1.2014 stating that the policy is subject to policy clause 4.3 according to which there is 4 years waiting period for the expenses related to treatment of joint replacement. Though the policy is in force since 2002, the sum insured is enhanced from Rs.3,00,000/- to Rs.3,50,000/- under the current year policy. The sum insured has been enhanced from Rs.3,00,000/- to Rs.3,25,000/- during last year and to Rs.3,50,000/- during the current year. If the policy is renewed for enhanced sum insured, then the restrictions as applicable to a fresh policy (condition 4.1, 4.2 and 4.3) will apply to additional sum insured as if a separate policy has been issued for the difference. The enhanced sum insured has not completed the waiting period of 4 years to be considered for settlement under policy clause 4.3 Rs.3,00,000/- only qualifies to be considered as this limit has completed the necessary waiting period under the said clause. In view of the above the opposite parties considered 70% of the applicable sum insured of Rs.3,00,000/- in accordance with the policy provisions and settled the claim for Rs.2,10,000/-. The 2nd opposite party sent again reimbursement claim approval letter Ex.A.8 dated 25.2.2014 stating that as per the instructions of the 1st opposite party the claim is being settled as per the mediclaim computation sheet attached. On receiving the same the complainant got issued a legal notice Ex.A.9 dated 4.3.2014 to the opposite parties demanding the opposite parties to verify the facts and to arrange the balance payment of Rs.35,000/- with interest at the rate of 24% per annum from the date of claim to till date of payment. As otherwise the complainant will approach the proper Forum for relief and compensation of Rs.50,000/-. The opposite parties received the same under Ex.A.10 and Ex.A.11 and issued reply notice Ex.A.12 dated 21.3.2014 stating that
Hospitalization Benefits | Limits per surgery restricted |
(a) cataract, hernia, hysterectomy | (a) Actual expenses incurred or 25% of the sum insured whichever is less. |
(b) Major surgeries | (b) actual expenses incurred or 70% of the sum insured whichever is less. |
Further it is observed from discharge summary that the complainant underwent left total knee replacement in 2011. The sum insured is increased from Rs.3,00,000/- to Rs.3,25,000/- from 27.2.2012 and to Rs.3,50,000/- with effect from 27.2.2013 . Hence the ailment is pre-existing to the increased sum insured. The opposite parties have settled the claim as per the terms and conditions of the policy. The opposite parties filed the policy copy Ex.B.1 issued to complainant by the opposite parties for the period of insurance from 27.2.2013 to 26.2.2014.
7. On hearing the both counsels arguments, we, the Forum noted that if the policy is to be renewed for enhanced sum insured then the restrictions as applicable to a fresh policy (condition Nos.4.1, 4.2 and 4.3) will apply to additional sum insured) as if a separate policy has been issued for the difference.
8. The sum insured has been enhanced from Rs.3,00,000/- to Rs.3,25,000/- during 27.2.2012 to 26.2.2013 and it was enhanced Rs.3,25,000/- to Rs.3,50,000/- during the current year from 27.2.2013 to 26.2.2014. The complainant joined in the hospital on 1.8.2013 for right total knee replacement. If the policy renewed for enhanced sum insured, then the restrictions are applicable to a fresh policy under condition Nos.4.1, 4.2 and 4.3 to additional sum insured as if a separate policy has been issued for the difference and the enhanced sum insured has not completed, the waiting period of four years. His right total knee was replaced within six months of taking enhanced policy. Hence for settlement of amount will be considered under policy clause 4.3 Rs.3,00,000/- only qualifies to be considered as the previous policy has completed the necessary waiting period of four years under the said clause. In view of this the opposite parties considered 70% of the applicable sum insured of Rs.3,00,000/- in accordance with the policy provisions and settled the claim for Rs.2,10,000/-. It is observed by the opposite parties from discharge summary that the complainant underwent left total knee replacement in 2011, and therefore the sum insured is increased from Rs.3,00,000/- to Rs.3,25,000/- from 27.2.2012 to 26.2.2013 and Rs.3,25,000/- to Rs.3,50,000/- from 27.2.2013. Hence the ailment is pre-existing to the increased sum insured. In view of the above observation we came to opinion that the opposite parties settled the claim as per the terms and conditions of the policy and there is no deficiency in service on the part of the opposite parties towards the complainant and the complainant is not entitled for any relief as prayed. Accordingly these points are answered.
POINT No.3:-
9. In the result, the complaint is dismissed without costs.
Typewritten by Stenographer K.Sivaram Prasad, corrected by me and pronounced by us in the open Forum, this the 23rd day of September, 2014.
PRESIDENT(FAC) MEMBER
APPENDIX OF EVIDENCE
WITNESSES EXAMINED
For the complainant: For the opposite parties:-
P.W.1 Dr.K.Kishore Babu, D.W.1 V.Sunil Kumar,
Complainant Deputy Manager
(by affidavit) Of the 2nd opposite party (by affidavit)
DOCUMENTS MARKED
On behalf of the Complainant:-
Ex.A.1 . . Photocopy of Hospitalization and domiciliary
hospitalization benefit policy.
Ex.A.2 . . Individual Health Insurance Policy book let.
Ex.A.3 . . Copy of IP package detailed bill.
Ex.A.4 27.08.2013 Photocopy of letter from TTK Health care TPA Private Limited to the complainant.
Ex.A.5 31.08.2013 Photocopy of letter from the complainant to the TTK Healthcare TPA Private Limited, Visakhapatnam.
Ex.A.6 13.12.2013 Photocopy of letter from the complainant to the Branch Manager, TTK Healthcare TPA Private Limited,
Visakhapatnam.
Ex.A.7 08.01.2013 Photocopy of letter from the 1st opposite party to the complainant.
Ex.A.8 25.02.2014 Photocopy of letter from the 1st opposite party to the complainant.
Ex.A.9 04.03.2014 Office copy of legal notice along with postal receipts.
Ex.A.10 . . Postal acknowledgement.
Ex.A.11 . . Postal acknowledgement.
Ex.A.12 21.03.2014 Reply letter along with another letter dated 08.01.2013.
For the opposite parties:-
Ex.B.1 . . Individual Health Insurance Policy book let.
PRESIDENT(FAC)
