Date of Filing: 09.08.2014
Date of Order: 28.08.2018
BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM – I, HYDERABAD
P r e s e n t
HON’BLE Sri P.Vijender, B.Sc. L.L.B. PRESIDENT.
HON’BLE Smt. Kasturi, B.Com., LLM., MEMBER.
Tuesday, the 28th day of August, 2018
C.C.No.538/2014
Between
K.Raja Reddy,
S/o. K.Venkat Reddy,
Aged about 75 years, Indian,
Occ: Advocate,
D.No.1-2-56/52, Advocates Colony,
Domalguda, Hyderabad – 500059. ……COMPLAINANT
And
- M/s. UTI Infrastructure Technology & Services Ltd.,
Bank Street, Sultan Bazar,
Hyderabad.
Rep. by its Branch Manager.
- M/s. UTI Infrastructure Technology & Services Ltd.,
Southern Regional Office,
STC Trade Centre, 1st Floor,
A-29, Thiru Vi Ka, Industrial Estate,
Guindy, CHENNAI – 600032,
Rep. by its Managing Director. …..OPPOSITE PARTIES
Counsel for the complainant : M/s. V.Gouri Sankara Rao & Associates
Counsel for the Opposite Parties : Sri M.V.Pavan Kumar
O R D E R
(By Hon’ble Sri P.Vijender, B.Sc., LL.B., President on behalf of the bench)
This complaint is preferred alleging deficiency of service by the Opposite Parties and in consequence of it a direction to pay a sum of Rs.3,65,000/- with interest thereon at 18% p.a., from the date of complaint to the date of payment and compensation of Rs.50,000/- and costs of this complaint at Rs.25,000/-.
2. The complainant case in brief is that:
Unit Trust of India launched Senior Citizens Unit Plan for covering the medical expenses and as per the terms and conditions of it UTI will reimburse medical bills to a maximum amount of Rs.1,50,000/- on admission in selected Hospitals to the member his or her spouse to the same extent. The complainant having induced by the representations made by the marketing people of UTI joined in the scheme and was issued membership certificate in citizens unit plan on 07.07.1995. Identity Card was also issued to the complainant and his wife on 20.12.1996. Later UTI was converted into M/s. Unit Trust of India infrastructure Technology & Services Ltd., from 07.07.1995 onwards and the medical coverage of Rs.2,50,000/- was made available to the complainant from 07.07.2001 and an additional coverage to a tune of Rs.2,50,000/- was provided.
The complainant’s wife was admitted in Sunshine Hospitals Secunderabad on 03.01.2014 and undergone for total left knee replacement surgery. A final bill for Rs.2,40,000/- was issued while discharging her on 08.01.2014. At the time of discharge the complainant was found to be suffering from heart ailment. Hence, he was admitted underwent PTCA + Stent surgery in the same hospital and was discharged on 10.01.2014 and another bill for Rs.2,75,000/- was issued for his treatment. These bills were submitted for reimbursement and in the Identity Card Cum Log Book necessary entries were made by the concerned officials on 02.04.2014. On 17.02.2014 while deducting Rs.1,50,000/- each only the cumulative balance was shown as Rs.3,99,152.03 ps.,again on 24.03.2014 Rs.1,50,000/- was added to each and the balance amount was increased to Rs.5,45,152.03 ps., without explaining the reasons. The complainant received a Demand Draft dated 20.03.2014 for a sum of Rs.1,50,000/- towards settlement of medical claim on 24.03.2014.
The Opposite Party No.2 has not given any reasons as to why it offered only a sum of Rs.1,50,000/- towards two separate medical claims of Rs.2,40,000/- & Rs.2,75,000/- each was debited in the log book and why Rs.1,50,000/- was reduced having already entered.
On 15.04.2014 complainant submitted a representation to Opposite Party No.2 asking for payment of balance amount. The Opposite Party No.2 gave a reply stating that, under the provisions of the Scheme maximum limit amount is Rs.1,50,000/- for the claim and recurrence of any illness within 45 days from the date of discharge will be treated as the same illness, hence, only sum of Rs.1,50,000/- was paid.
The second ailment is heart problem for which PTCA + Stent surgery was made and it was not on account of the first surgery i.e., total left knee replacement operation. Both are independent deceases and have nothing to do with each other. Hence, Opposite Parties cannot treat both the ailments as a single claim to say that second cardiac problem is a complication of the orthopedic surgery. The explanation offered by Opposite Parties refusing to pay the second claim is due to non-application of the mind and it amounts to not only deficiency in service but also unfair trade practice. By refusing to pay for the second bill amount the Opposite Parties have caused serious inconvenience, hardship and mental agony to the complainant apart from causing irreparable financial loss and the Opposite Parties are liable to pay entire balance amount of Rs.3,65,000/-. Hence the present complaint.
3. The Opposite Parties filed a common written version denying the claim of the complaint their stand is, SCUP Scheme was launched by UTI under Section 21 of UTI Act, 1963 in collaboration with New India Insurance Company Ltd. The members under the scheme on making one time investment depending on the age of entry, will have the benefit of medical treatment in selected hospitals on completion of age of 58 years which facility is also available to the member as well as his or her spouse. After 61 years of age of member of his or her spouse are eligible for a further sum of Rs.2,50,000/- for medical coverage. UTI will pay premium to New India Assurance Company Ltd., to all the members who have competed 55 years of age against their investment. Recurrence of any illness within 45 days from the date of discharge from the Hospital will be treated as same illness. On attaining age of 54 years, the trust shall issue I.D. card cum Log Book to the member and his or her spouse. The trust have made arrangements with Insurance Company under the exclusive medical insurance cover whereby bills from the concerned Hospitals in connection with the treatment will be settled directly by the New India Assurance Company, up to prescribed limit. In the I.D issued to the members it is mentioned that there is a limit of Rs.1,50,000/- per illness per illness shall mean continuous period of illness if the patient has been re-hospitalized within 45 days from the date of discharge. Occurrence of same illness after lapse of 45 days will be considered as fresh illness and shall be eligible for fresh limits.
The complainant jointly with his wife had invested a sum Rs.31,100/- on 07.07.1995 and they were allotted certificates under the scheme. The amount invested by them has been utilized after attending the age of 55 years for payment of seven premiums to New India Assurance Company. On 03.01.2014 the complainant was admitted in the Hospital and underwent for total left knee replacement surgery. He was discharged on 08.01.2014. He was again admitted on the same day and underwent PTCA + Stent surgery in the same hospital and was discharged on 10.01.2014 and he stated to have paid two separate bills and submitted both the bills for reimbursement. The claim was settled by paying Rs.1,50,000/- on 20.03.2014 towards two separate claims of Rs.2,40,000/- and Rs.2,75,000/- and a separate letter was sent giving reasons for rejecting the rest of the claim, as per the condition-4 of UTI (SCUP) Mediclaim policy.
The complainant is dividing the treatment for two diseases for the same duration of the hospitalization. As per the terms and conditions the members under scheme hospitalization expenses for a particular duration shall be treated as one illness irrespective of number of diseases. New Assurance Company already settled medical bills for the eligible amount of Rs.1,50,000/- hence, the claim of the complainant for further sum of Rs.3,65,000/- is beyond the provisions of SCUP. Hence, the present complaint is frivolous litigation either deliberately or under wrong advice.
Any claim for payment beyond the expressed and agreed scheme provisions rather terms and conditions are not maintainable as held by Hon’ble State Commission of Madhya Pradesh in the case of Dilip Vs. New India Insurance Company Ltd., in Appeal No.1127/1999 reported in CPJ-1,2002. The Hon’ble National Commission also in the order Revision Petition No.2549/2006 in the case of UTI vs. Smt. Swarna Latha Jain held that unit holders are bound by terms and conditions of the Scheme and cannot therefore seek relief beyond the maximum claim limit of Rs.1,50,000/- per illness per spouse stipulated in the scheme. Hence, the complaint is liable to be dismissed.
4. In the enquiry stage the complainant has filed his evidence affidavit reiterating the material averment of the complaint and got exhibited 6 documents which are not in dispute. Similarly on behalf of the Opposite Parties the evidence affidavit of one Mr. Surendra H.Goud stated to be incharge of Opposite Party No.1 is file he too reiterated materials contentions raised in the written version and got exhibited 10 documents which are also not in dispute.
5. Both sides have filed written arguments and supplemented the same with oral submissions.
6. On a consideration of material on record the following points have emerged for consideration.
- Whether the complainant is entitled for sum of Rs.1,65,000/- with interest ?
- Whether there is deficiency of service on the part of the Opposite parties entailing the complainant to claim compensation?
- To what relief?
- Point No.1: As per the complainant’s claim he was admitted in the Sunshine Hospital on 03.01.2014 and underwent total left knee replacement surgery and while being discharged on 08.01.2014 he was found to have been suffering with heart ailment, hence was readmitted in the same Hospital on the same day and underwent PTCA + Stent surgery and was discharge on 10.01.2014. The Hospital issued two (2) final bills on 08.01.2014 for left knee replacement surgery amounting to Rs.2,40,000/- and another bill dated 10.01.2014 for the PTCA +Stent Surgery for a sum of Rs.2,75,000/- and both these ailments are not one and the same. The heart ailment is not due to complication of Orthopedic Surgery hence, the Opposite Parties shall consider both these treatments as separate one of reimbursement. Whereas, the essence of the contest of Opposite Party is recurrence of any illness age within 45 days from the date of discharge from the hospital will be treated as same illness. Condition-4 of I.D Card and Log Book issued also says there is a limit of 1.5 Lakhs per illness for spouse and it means if, the patient re-hospitalized within 45 days from the date of discharge for illness it will be treated as same illness. Ex.A1 is Identity Card cum Log Book and instruction NO.4 of it reads as under :-
- There is a maximum limit of Rs.1.5 Lakhs per illness per spouse. Recurrence of any illness within 45 days from the date of discharge from hospital will be treated as same illness. The word used in the above instruction is recurrence any illness and not recurrence of same illness and also the word used is maximum limit of Rs.1,50,000/-. Hence irrespective of the fact that heart ailment was diagnosed on the date of discharge after the total knee replacement surgery also come under any illness because it within 45 days.
The Learned Counsel for the complainant placed reliance in the case of Kesari Hanumantha Rao, Appellant Vs. UTI & Others in F.A.No.709/2013 before the A.P. State Commission, Hyderabad. The facts in the said case are identical to the facts of the present case. The Hon’ble Commission while setting aside the orders of the District Forum allowed the Appeal holding that treatment to two different diseases and they have to be treated different ailments and there is no nexus between both the diseases and the complainant is entitled for insured amount for both the diseases. Whereas, the Learned Counsel for the Opposite Parties placed reliance in the case of UTI & Another Vs. Swarna Latha Jain and Another by the Hon’ble National Consumer Disputes Redressal Commission and in the said case the complainant stated to incurred an expenditure of Rs.2,65,000/- and submitted a claim for settlement before the Opposite Parties who settled the claim for Rs.1,50,000/- and aggrieved by it, a Company was preferred before the District Forum and the same was allowed against which an appeal was preferred before the State Commission and same was dismissed and aggrieved by it the Opposite Parties preferred a Revision Petition before the Hon’ble National Commission. The Hon’ble National Commission held that, UTI SCUP Scheme clearly states that there will be a limit of Rs.1.50,000/- for any one illness and since entire scheme was notified in the Gazette of India No.288/1993 and here also it is clearly stated under clause-5 that, the amount for medical claim under this scheme shall be limited to maximum of Rs.1,50,000/- per illness. Form-A which is UTI SAUP Membership certificate and part of the Gazette Notification also specifically states that, there will be a maximum limit of Rs.1,50,000/- per illness per spouse. Since, the scheme is widely published through notification in the Gazette of India those joining it as members cannot take plea ignorance of its terms and conditions. Therefore, they are bound by the terms and conditions of the Scheme and cannot therefore seek relief beyond the maximum claim limit per person / per illness stipulated in the scheme. Hence, the entitlement of the complainant therein was only Rs.1,50,000/- which was settled by the Opposite Parties. .
- In the light of the above findings of the Hon’ble National Commission there is no other go except to say that, the entitlement of the complainant is only Rs.1,50,000/- which is a maximum available per illness to the member of the scheme. Hence, the complainant is not entitled for the amount of Rs.3,65,000/- as claimed. Accordingly the point is answered.
- Since, the Opposite Parties acted according to the terms and conditions of the Policy and paid the maximum amount as per the scheme, there is no deficiency of service on their part. As such, the complainant is not entitled for any compensation. Accordingly, the point is answered.
- Point No.2: In the result, the complaint is dismissed and no orders as to costs.
Typed by Typist, corrected and pronounced by us on this the 28th day of August, 2018.
MEMBER PRESIDENT
APPENDIX OF EVIDENCE
PW1 DW1
Sri K.Raja Reddy, Sri Surendra H.Goud
Exs. filed on behalf of the Complainant:
Ex.A1 is copy of Senior Citizens’ Unit Plan Identity Card & Log Book.
Ex.A2: is copy of Inpatient final Bill dt.08.01.2014.
Ex.A3: is copy of Inpatient final Bill dt.10.01.2014. .
Ex.A4 is copy of Angiogram Report, dt.08.01.2014.
Ex.A5: is copy of Sunshine Hospital description dt.02.01.2014.
Ex.A6: is copy of UTI Letter of O.P. dt.21.04.2014.
Exs filed on behalf of the Opposite party
Ex.B1 is copy of Authorization letter.
Ex.B2 is copy of the Repealing Act.
Ex.B3 is copy of Appointment of UTI-ITSL as Registrar & Transfer Agent Document.
Ex.B4 is copy of Identity Card & Complete Log Book issued to the Unit Holder.
Ex.B5 is copy of SCUP Scheme Gazette.
Ex.B6 is copy of Specimen Application form of SCUP Scheme.
Ex.B7 is copy of Tripartite Agreement dt.25.08.1993 and Supplement Agreement.
Ex.B8 is copy of Letter dt.15.04.2014 of the complainant.
Ex.B9 is copy of Letter dt.21.04.2014 of the Opposite Party.
Ex.B10 is copy of the authorization appointing UTI Asset Management Co., Pvt., Ltd., (UTI-AMC) by the UTI Trustee Co., Pvt. Ltd., to manage the funds collected under the Schemes mentioned in Schedule –II of the Repealing Act, vide investment agreement dt.09.12.2002.
MEMBER PRESIDENT
