DISTRICT FORUM :: KADAPA
PRESENT: SRI P.V. NAGESWARA RAO, M.A., LL.M., PRESIDENT
SRI S. ABDUL KHADER BASHA, B.Sc., MEMBER
Tuesday, 15th July 2008
CONSUMER COMPLAINT No. 20 / 2008
G. Jagadeesh Babu, S/o Subbarayudu, aged 50 years,
Resident of D.No. 13/499, Upstairs, Y.V. Street,
Kadapa. ….. Complainant.
Vs.
1) M/s Good Health Plan Limited,
H.O. 8-2-1/B1, S.V.R Towers, 4th floor,
Srinagar Colony Road, panjagutta, Hyderabad – 500 082.
2) The Divisional Manager, new India Insurance Co. Ltd.,
Divisional Office, 2/789, 1st floor, Sairam Towers,
Nagarajupeta, Kadapa. ….. Respondents
This complaint coming on this day for final hearing on 7-7-2008 in the presence of Sri C.K. Bramhaiah, Advocate for complainant and Sri D. Lakshminarayana, Advocate for R2 and R1 called absent and set exparte on 29-5-2008 and upon perusing the material papers on record, the Forum made the following:-
O R D E R
(Per Sri P.V. Nageswara Rao, President),
1. Complaint filed under section 12 of the Consumer Protection Act.
2. The brief facts of the complaint is as follows:- The complainant took one “Hospitalization and Domiciliary Hospitalization Benefit Policy” covering the risk of Rs. 1,00,000/- to him. In 2006 the complainant took the same policy for covering the risk for Rs. 1,00,000/- by renewing the earlier policy. In 2007 the complainant obtained the same policy by renewing the earlier policy enhancing the covering the risk from Rs.1,00,000/- to Rs.2,00,000/- commencing from 31-1-2007 to 30-1-2008. The 2ndrespondent issued policy certificate bearing No. 611200/34/06/20/00000059 covering the risk of Rs. 2,10,000/- including bonus of Rs. 10,000/- for non claiming the benefit in previous year under the policies.
3. In May 2007 the complainant became sick and consulted Dr. G. Ramakrishna Reddy at Kadapa who noticed heat complaint of the complainant. The complainant went Bangalore WOCKHARDT hospitals in June 2007 where he underwent a bypass surgery on 27-6-2007 and was in hospital for 8 days by spending Rs. 2,05,335/- i.e. Rs. 1,87,315/- towards surgery and hospitalization charges and Rs. 18,020/- towards angiogram charges. The complainant sent two claim forms separately one for Rs. 1,87,315/- and another for Rs. 18,020/- to the R1, who was none other than third party administrator (T.P.A) of the 2nd respondent and sent a copy to R2. The R1 paid Rs. 17,020/- towards angiogram expenses and Rs. 83,018/- towards surgery and hospitalization charges by disallowing balance claim. The complainant later wrote a letter to R1 on 8-9-2007 stating that the policy would cover the risk of Rs. 2,10,000/-. So he was entitled to the said amount. On 22-9-2007 and on 8-10-2007 the complainant sent two reminders to R1 for settlement of balance amount of Rs. 1,00,000/- and sent copies to R2. The R1 after receiving the 2nd reminder sent a cheque for Rs. 9,962/-. Thus the complainant received in total Rs. 1,10,000/- by way of three cheques, dt. 18-8-2007 for Rs. 17,020/-, dt. 30-8-2007 for Rs. 83,018/-, dt. 13-10-2007 for Rs. 9,962/-. The complainant was entitled to receive the balance amount of Rs. 95,335/- towards policy from the respondents. The complainant got issued a legal notice but there was no response.
4. The R1 disallowed the balance amount by saying that the maximum credit limit was Rs. 1,00,000/-. Therefore, the complaint was filed for Rs. 95,335/- towards expenses from both the respondents jointly and severally, with interest at 24% p.a and Rs. 3,000/- towards expenses.
5. The R1 was called absent and set exparte on 29-5-2008.
6. The R2 filed a counter admitting the policy for Rs. 1,00,000/- for complainant and Rs. 1,00,000/- to his wife and Rs. 50,000/- to each of his three children covering the period from 31-1-2006 to 30-1-2007 and also the renewed the policy for the period from 31-1-2007 to 30-1-2008 by enhancing the additional amount of Rs. 1,00,000/- for himself alone, without enhancing to the family members.
7. Exclusion clause 4.1 of the policy disclosed “pre-existing diseases / conditions: All diseases / injuries / conditions, which are pre-existing when the cover incepts for the first time (except as shown hereunder). Any complication arising from pre-existing / ailment / injury will be considered as a part of pre-existing condition. This exclusion will be delayed after 4 consecutive claim free policy year provided there was no hospitalization for the pre-existing disease / ailment / condition / injury during the said four years of insurance with our company.
8. Compulsory coverage for specific pre-existing conditions: on payment of additional premium which is compulsory for persons suffering from pre-existing conditions of Diabetes mellitus and Hypertension these specific pre-existing conditions only are covered in the following manner.
1st year | No claim |
2nd year | No claim |
3rd year | 50% of admissible claim or 50% of the sum insured set for the individual whichever is less |
4th year | 75% of admissible claim or 75% of the sum insured set for the individual whichever is less |
5th year onwards | 100% of admissible claim or sum insured set for the individual whichever is less. |
9. It was an admitted fact that the complainant was admitted in hospital at Bangalore and underwent bypass surgery by spending Rs. 2,05,335/-. The letter dt. 25-5-2007 sent by the complainant to R1 disclosed that it was a known case of IHD (Ishaemic Heart Disease) HTN (Hyper Tension) and Type – II DM (Diabetes Mellitus). The enhancement of the policy of Rs. 1,00,000/- was made on 31-1-2007. It was the decision of the company to accept or reject the coverage of any person at renewal and also revise the premium rates and terms and conditions of the policy. The premium due must be paid before due date. If the policy was to be renewed for enhanced sum insured, that the restriction as applicable to a fresh policy would apply to additional sum insured as if a separate policy was issued for difference. In other words, the enhanced sum insured would not be available for any illness, disease, injury already contracted under the preceding policy periods. Knowing fully well that he was suffering from heart disease the complainant renewed with enhancement of Rs. 1,00,000/- and got the policy. The complainant was a known heart patient. Therefore, the enhanced amount was disallowed. The complainant received Rs. 1,10,000/- and so there was no deficiency of service and the complaint may be dismissed with costs.
10.On the basis of the above pleadings the following points are settled for determination.
i. Whether the complainant is entitled for the relief as prayed for?
ii. Whether there is any deficiency of service on the part of the respondents?
iii. To what relief?
11.On behalf of the complainant Ex. A1 to A19 were marked and on behalf of the respondents Ex. B1 to B7 were marked.
12.Point Nos. 1 & 2. There was no dispute regarding the policy under “Hospitalization and Domiciliary Hospitalization benefit Policy” covering the risk of Rs. 1,00,000/- for complainant and Rs. 1,00,000/- to his wife and Rs. 50,000/- to each of his three children covering the period from 31-1-2006 to 30-1-2007. Ex. A19 was Xerox copy of policy covering the period from 31-1-2006 to 30-1-2007. Ex. A1 was Xerox copy of renewed policy covering for the period from 31-1-2007 to 30-1-2008. The R2 filed the copies of the same policies under Ex. B7 & B6. Under Ex. A1 the complainant enhanced the sum insured from Rs. 1,00,000/- to Rs. 2,00,000/- and paid extra premium also. The total premium paid was Rs. 7,503/- under Ex. A1. Under Ex. A19 the premium was Rs. 5,447/-. Since the assured sum was enhanced the R2 company collected more premium amount from the complainant. There was no dispute that the complainant underwent a bypass surgery at WOCKHARDT Hospitals, Bangalore by spending Rs. 2,05,335/-. Prior to admitting in the hospital at Bangalore the complainant consulted G.S.R Heart Care Center, Kadapa belonged to Dr. G. Ramakrishna Reddy on 25-5-2007, who noticed heart problem of the complainant. Ex. A2 was Xerox copy along with report issued by GSR Heart care center, Kadapa.
13.The complainant visited WOCKHARDT Hospitals, Bangalore for coronary angio report and the same was issued on 22-6-2007. The Xerox copy of report was Ex. A3. Ex. A4 to A8 were Xerox copies of out patient bills. Ex. A9 was Xerox copy of discharge summary dt. 23-6-2007. The complainant was operated on 27-6-2007 and was discharged on 3-7-2007 at WOCKHARDT Hospitals, Bangalore. Ex. A10 was Xerox copy of discharge summary dt. 3-7-2007. Ex. A11 was Xerox copy of claim form. Ex. A12 was Xerox copy of letter sent by the complainant to R1 requesting to allow the claim of another Rs. 1,00,000/-. A copy of it was sent to R2. Ex. A13 and A14 were Xerox copies of reminders to R1. Ex. A15 was office copy of notice issued to both the respondents. Ex. A16 was Xerox copy of letter dt. 20-8-2007 from R1 that a cheque for Rs. 17,020/- was sent as on approved amount. Ex. A17 was another Xerox copy of letter from R1 dt. 30-8-2007 sending a cheque for Rs. 83,018/-. Ex. A18 was another Xerox copy of letter, dt. 13-10-2007 from R1 issuing a cheque for Rs. 9,962/-. On the whole the complainant received Rs. 1,10,000/- by way of three cheques on three different dates as mentioned under Ex. A16, A17 and A18. It was also an admitted the fact.
14. The respondent filed a Xerox copy of Rules and Regulations of Medi claim policy under Ex. B1. Ex. B2, B3 and B4 were the letter from R1 to the complainant and same copies have been filed by the complainant under Ex. A16, A17 and A18. The R2 filed Ex. B5 a Xerox copy of letter from R1 to R2 that the complainant was already suffering from IHD, HTn and Type II DM in view of his reports. On the basis of Ex. B5 the R2 disallowed the claim of the complainant for Rs. 95,335/-. In view of Ex. B6 and A1 the complainant enhanced the sum insured from Rs. 1,00,000/- to Rs. 2,00,000/- and paid premium at enhanced rate. Under the enhanced sum insured the premium for the complainant alone was Rs. 3,900/- where as the premium was only Rs. 2,039/- for Rs. 1,00,000/- insured under Ex. A19 and Ex. B7. Therefore, the complainant is entitled for the claim amount of Rs. 95,335/- from R1 and R2. The respondents should have paid the amount much earlier as soon as they received the notice Ex. A15. But they were silent. Thus there is deficiency of service on the part of the respondents.
15. Point No. 3. In the result, the complainant is allowed directing the respondents 1 & 2 jointly and severally to pay Rs. 95,335/- with interest @ 9% p.a from the date of petition till the date of realization along with costs of Rs. 1,000/-. And also directing the R1 & R2 jointly and severally should pay within 60 days from the date of receipt of this order.
Dictated to the Stenographer, transcribed by him, corrected and pronounced by us in the open forum, this the 15th July 2008
MEMBER PRESIDENT
APPENDIX OF EVIDENCE
Witnesses examined.
For Complainant : NIL For Respondent : NIL
Exhibits marked for Complainant : -
Ex. A1 X/c of policy issued in favour of G. Jagadeesh Babu.
Ex. A2 X/c of cardiologist report dt. 25-5-2007.
Ex. A3 X/c of coronary angio report dt. 22-6-2007.
Ex. A4 X/c of out patient bill, dt. 21-6-2007.
Ex. A5 X/c of inpatient bill, dt. 23-6-2007.
Ex. A6 X/c of Inpatient bill, dt. 3-7-2007
Ex. A7 X/c of out patient bill, dt. 5-7-2007.
Ex. A8 X/c of out patient bill, dt. 7-7-2007
Ex. A9 X/c of discharge summary dt. 23-6-2007
Ex. A10 X/c of discharge summary, dt. 3-7-2007.
Ex. A11 X/c of claim form.
Ex. A12 X/c of letter from complainant to R1 , dt. 8-9-2007.
Ex. A13 X/c of letter from complainant to R1, dt. 22-9-2007.
Ex. A14 X/c of 2nd reminder from complainant to R1, dt. 8-10-2007.
Ex. A15 office copy of legal notice, dt. 7-12-2007.
Ex. A16 X/c of letter dt. 20-8-2007 from R1to complainant.
Ex. A17 X/c of letter dt. 30-8-2007 from R1to complainant
Ex. A18 X/c of letter dt. 13-10-2007 from R1to complainant
Ex. A19 X/c of policy issued by R2 in favour of complainant.
Exhibits marked for Respodnents : -
Ex. B1 X/c of Rules and regulations of the policy.
Ex. B2 X/c of letter from R1 to complainant, dt. 20-8-2007.
Ex. B3 X/c of letter from R1 to complainant dt. 30-8-2007.
Ex. B4 X/c of letter from R1 to complainant, dt. 13-10-2007.
Ex. B5 X/c of letter from R1 to R2, dt. 7-9-2007.
Ex. B6 X/c of policy issued in favour of the complainant.
Ex. B7 X/c of policy issued in favour of the complainant.
MEMBER PRESIDENT
Copy to :-
1) Sri C.K. Bramhaiah, Advocate, Kadapa.
2) Sri D. Lakshminarayana, Advocate, Kadapa.
3) M/s Good Health Plan Limited, H.O. 8-2-1/B1, S.V.R Towers, 4th floor, Srinagar Colony Road, Panjagutta, Hyderabad – 500 082.
1) Copy was made ready on :
2) Copy was dispatched on :
3) Copy of delivered to parties :
B.V.P. - - -
......................Sri P.V. Nageswara Rao
......................Sri.S.A.Khader Basha |
