This case coming on 04.12.2014 for final hearing before this Forum in the presence of Sri M. Narasimha Rao, Advocate for the complainant and Sri Iftekhar Mahamood , Advocate for the opposite parties and having stood over to this date for consideration, this Forum pronounced the following:-
O R D E R
(By Sri A. Radha Krishna, President on behalf of the Bench)
1. Claiming refund of Rs. 1,35,000/- together with compensation of Rs. 5,000/-. The complainant laid this claim interalia contending he is a retired Bank Officer. Opposite party two is authorized agent of opposite party one who is National Insurance Company Ltd. According to him he obtained policy from opposite party one for hospital expenses which is valid from 31.03.2009 to 30.03.2010. He was admitted in Sri Venugopal Memorial Nursing Home for Angina attack and was treated for 4 days. His hospital expenses of Rs. 5,641-80 ps were also reimbursed by opposite party one through opposite party two. As per the terms and conditions of the policy he is entitled for post hospitalization charges upto 60 days from the date of discharge.
2 It is also his contention he underwent treatment for the same disease in Saaol Heart Centre, Himayat Nagar, Hyderabad as outpatient and spent nearly Rs.1,35,000/-. Immediately he lodged his claim with opposite party two, agent of opposite party one. After prolonged correspondence the opposite parties repudiated the claim on the ground that the treatment obtained by him was Naturopathy under clauses 4.13 and 4.23. Further according to him the treatment obtained by him is Allopathy and not Naturopathy. He also issued lawyer’s notice to opposite party one having received the same they requested to provide correspondence made by him. Though his sent the same neither the opposite party one paid the amount nor sent any reply. Thus he sought the above said compensation.
3 The 1st opposite party filed its written version adopted by 2nd opposite party. They denied the material allegations levelled against them by the complainant and further according to them the complainant is known for coronary artery disease. He also underwent bypass surgery in the month January, 2009 and later medication Angina and got himself examined by Dr. Y.S.K. Nath, Venugopal Memorial Nursing Home and he was evaluated with outpatient related investigations and in that connection he submitted claim for Rs. 5,641/-. Though it could not be considered in view of clause 4.23 of the terms and conditions it was settled by them with benefit of doubt considering his age and his policy having a CB of 35%. Later the complainant basing on the said claim as a main claim planned expensive outpatient treatment of enhanced external counter pulsation of 35 sittings at another hospital to post hospitalization treatment which is not valid as per the conditions of the policy. It is also their case the treatment procedure EECP [Enhanced External Counter Pulsation] is totally different unproven treatment which the complainant obtained in another hospital not related to earlier ailment. The said procedure of EECP is not covered under policy clause 4.23. Further his claim also comes under Naturopathy treatment for which the complainant is not entitled the expenses as per clause 4.13. Thus according to them there is no deficiency of service on their part and thus sought dismissal of the complaint.
4 Now the points for determination are:
- Whether there is any deficiency of service on the part of opposite parties as contended by the complainant?
- If so, whether the complainant is entitled for the amount claimed in the complaint?
- To what relief?
5. Point No.1: To prove his claim the complainant apart from examining himself as PW1 also examined Dr. Pallampati Srinivasarao as PW2 who is Doctor Saaol Heart Centre, Hyderabad. The complainant also exhibit as many as 21 documents marked as Exs. A1 to A21. Ex.A1 is the policy issued by the opposite party one in favour of the complainant, Ex.A2 is letter issued by Sri Venugopal Memorial Nursing Home, Ex.A3 is settlement advise issued by Medi Assist opposite party two, Ex.A4 is copy of the letter addressed by the complainant to opposite party two along with claim form; Ex.A5 is the letter addressed by opposite party two to the complainant expressing their inability to admit the liability; Ex. A6 is office copy of the letter addressed by the complainant to Medi Assist opposite party two, Ex.A7 is postal acknowledgment; Ex.A8 & A9 are the brochers of Saaol Heart Centre, Hyderabad, Ex.A10 is office copy of lawyer’s notice issued by the complainant to the 1st opposite party; Ex.A11 is postal acknowledgment, Ex.A12 is letter addressed by the 1st opposite party to complainant requesting him to send the correspondence made by him; Ex.A13 is the office copy of lawyer’s notice issued by him; Ex.A14 is postal acknowledgment; Ex.A15, Ex.A16 & Ex.A17 are xerox copies of receipts issued by Saaol Health Centre, Hyderabad, Ex.A18 consolidated bill issued by Saaol hospital; Ex.A19 & 20 are the copies of EECP and Bio Chemical Angiography; Ex.A21 is Health of tests conducted by Saaol Heart Centre, Hyderabad.
6. On the other hand challenging the version of the complainant the 1st OP examined one SSS Krishnarao, Assistant Manager as RW1 and also examined Dr. C. Mohan Reddy, Medical Officer as RW2, and exhibit B1 and B2 which are the true copy of the medi claim individual policy and the modified terms and conditions of the policy.
7. Both the parties reiterated their versions setout in the complaint and written version through PW1 and PW2 and RW1 and RW2 respectively.
8 Though it is the contention of 1st opposite party that the treatment obtained by the complainant is Naturopathy, the evidence of RW2 Homeo Doctor would indicate the treatment obtained by the complainant is Allopathy. Here it may pointed out that the modified terms and conditions exhibited as Ex.B2 was in fact not supplied to the complainant at the time of issuing the policy as evidence by version of RW1 who claims while issuing the medi claim of individual policy their officials by mistake and oversight failed to enclose the modified terms and conditions of the policy in the place of previous policy conditions. Thus the complainant can not be imputed with the knowledge of the modified terms and conditions under which the 1st opposite party taking shelter.
9. Here it may be pointed out that though the complainant claims Rs. 1,35,000/- post hospitalization expenses, his own document Ex.A2 issued by Sri Venu Gopal Memorial Nursing Home reveals he was given necessary injection to reduce Angina and prescribed additional medicines to be taken along with previous medicines. Further it also shows the complainant was cured of the complaint and relieved on 29.08.2009 and advised to continue on medicine.
10 The version of the complainant as evidence under Ex.A4 copy of letter addressed to Medi Assist opposite party two that when again contacted NIMS, Hyderabad and also KIMS they advised again Angiogram and stunt fixing is not supported by any material produced by the complainant. Thus his approaching Saaol Heart Centre afraid of intervention treatment as mentioned by him in Ex.A4 is only on his own accord and not supported by any other material. Thus his whole claim that he approached Saaol Heart Centre, fearing Angiogram and stunt fixing as advised by NIMS and KIMS, Hyderabad is without any basis. Thus the whole claim of the complainant that he incurred expenses Rs. 1,35,000/- and as the opposite parties repudiated the claim that amounts deficiency of service has no legs to stand. Hence this point is answered against the complainant and in favour of opposite parties.
11. Point No.2: In view of the discussion and finding rendered under point No.1 the point is also answered against the complainant.
12. Point No.3: In the result the complaint is dismissed in the circumstances without costs.
Typed by the Steno, transcribed by her, corrected and pronounced by us, in open Forum, this the 16th day of December, 2014
Sd/- xxxx Sd/- xxxxxxx
MEMBER PRESIDENT
APPENDIX OF EVIDENCE
WITNESSES EXAMINED
For complainant :
PW1: Complainant
PW2: Dr. Pallampati Srinivasarao
For opposite parties:
RW1: Sri SSS Krishnarao, Assistant Manager
RW2: Dr. C. Mohan Reddy, Medical Officer
DOCUMENTS MARKED
For complainant:-
Ex.A1 24.03.2009 Policy issued by the opposite party one in favour of the complainant
Ex.A2 29.08.2009 Letter issued by Sri Venu gopal Memorial Nursing Home
Ex.A3 27.10.2009 Settlement advise issued by Medi Assist 2nd opposite party
Ex.A4 09.11.2009 Copy of the letter addressed by the complainant to 2nd opposite party along with claim form
Ex.A5 04.01.2010 Letter addressed by 2nd opposite party to the complainant expressing their inability to admit the liability
Ex. A6 07.01.2010 Office copy of the letter addressed by the complainant to Medi Assist 2nd opposite party
Ex.A7 Postal acknowledgment
Ex.A8 Brocher of Saaol Heart Centre, Hyderabad
Ex.A9 Brocher of Saaol Heart Centre, Hyderabad
Ex.A10 19.02.2010 Office copy of lawyer’s notice issued by the complainant to the 1st opposite party
Ex.A11 Postal acknowledgment
Ex.A12 25.02.2010 Letter addressed by the 1st opposite party to complainant requesting him to send the correspondence made by him
Ex.A13 18.03.2010 Office copy of lawyer’s notice issued by him
Ex.A14 Postal acknowledgment
Ex.A15 04.09.2009 Xerox copy of receipt issued by Saaol Health Centre, Hyderabad
Ex.A16 01.10.2009 Xerox copy of receipt issued by Saaol Health Centre, Hyderabad
Ex.A17 05.10.2009 Xerox copy of receipt issued by Saaol Health Centre, Hyderabad
Ex.A18 27.10.2009 Consolidated bill issued by Saaol hospital
Ex.A19 07.11.2009 Copy of EECP and Bio Chemical Angiography
Ex.A20 07.11.2009 Copy of EECP and Bio Chemical Angiography
Ex.A21 27.11.2009 Health of tests conducted by Saaol Heart Centre, Hyderabad.
For opposite parties:-
Ex.B1 24.03.2009 True copy of the medi claim individual policy
Ex.B2 Modified terms and conditions of the policy
Sd/- xxxx Sd/- xxxxxxx
MEMBER PRESIDENT
