Andhra Pradesh

Visakhapatnam-II

CC/98/2013

B. Padmavathi - Complainant(s)

Versus

National Insurance Company Limited - Opp.Party(s)

C. Syama Sundara Rao

27 May 2015

ORDER

 Reg. of the Complaint:29-04-2013

                                                                                                                                      Date of Order:27-05-2015

BEFORE THE DISTRICT CONSUMERS FORUM-II

AT VISAKHAPATNAM

                   Present:

1.Sri H.ANANDHA RAO, M.A., L.L.B.,

       President

2.Sri C.V.RAO, M.A., B.L.,

                                             Male Member

3.Smt.K.SAROJA, M.A., B.L.,

       Lady Member

                                            

 

WEDNESDAY, THE 27^TH DAY OF MAY, 2015

CONSUMER CASE NO.98/2013

 

BETWEEN:

Smt.B.Padmavathi W/o Sri B.R.R.Murthy,

Hindu, aged 53 years, Retired Bank Employee,

R/a D.no.50-44-8/1/1, P & T Colony,

Seethammadhara, Visakhapatnam-530 013.

…Complainant

AND:

 

1.M/s National Insurance Co., Ltd., Divisional Office No.1,

Rep. by its Divisional Manager, Diamond Park Road,

Dwarakanagar, Visakhapatnam-530 016.

2.M/s Good Health Private Limited,  Rep. by its Managing Diretor,

8-2-1/B/1, SVR Towers, 4^th Floor, Srinagar Colony Road,

Panjagutta, Hyderabad-500082.

…Opposite Parties

This case coming on 19-05-2015 for final hearing before us in the presence of SRI SYAMA SUNDARA RAO, Advocate for the Complainant, and of SRI A.VENUGOPALA RAO, Advocate for the 1^ST Opposite Party, and 2^nd Opposite Party is being set exparte and having stood over till this date for consideration, this Forum made the following.

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         

ORDER

 (As per the Honourable President on behalf of the Bench)                                                                              

 

1. The complainant filed the present complaint against the OPs for payment of Rs.10,784/- with interest @ 18% p.a., from 2.7.2012 till the date of payment, Rs.20,000/- towards compensation for causing mental agony  and Rs.20,000/- towards damages and Rs.10,000/- towars costs.
2. The case of the complaint is that she has taken a mediclaim insurance policy i.e., BOI National Swatch Bheema Policy with the 1^st OP for her entire family consisting of complainant and her husband and married daughter Ms.Nikhila in the year 2007 with a fond hope to get medical aid for her family members in case of any calamities and the said policy was renewed on 12-09-2012 with policy no.560100/48/12/850000458 and the policy covers year from 17-09-2012 to midnight of 16-09-2013, the 2^nd OP is the 3^rd Party Administrator in between the policy holder and the insurance company for settlement of claims and their office is at Hyderabad with her daughter Ms.Nikhila admitted in Sunitha Nurshina Home due to some dental prolem and as per the directions of the medical officer her daughter was admitted in the nursing home on 30-06-2012 for the dental surgery and was discharged on 3-7-2012 as a result she incurred an amount of Rs.10,784/- for the surgery, medicines and and nursing home charges and after recoupment of her daughter, she made a claim to the OP by way of claim form on 18-07-2012 along with relevant bills and case sheet etc., for setttlment of claim as there was no response even for her e-mails. Hence, this complaint.
3. The case of OP1 denying material averments of the complaint, admitting the policy has taken by the complainant that as per the terms and condtions of the insurance policy at the time of hospitalization scheme intimation to the insurance company is mandatory requirement as per condition no.5.2. but in this case, the complainant has not intimated the same to them and thereby violated  the terms and conditions of th epolicey. There is a delay of nearly more than one month 9 days in intimating about the joining and treatment including dental surgery to her daughter and no request was made to condone the said delay and as such there is gross violation of terms and condtions committed by the complainant. They have taken up the matter with the TPA for review of their decision who opined the claim falls under exclusion no.4.7 terms and condtions. They convinced with the treatment taken by the complainant’s daughter was for normal dental treatment which is an exclusion under the policy. They have not admitted with regard to the several amounts claimed by the complainant. For these reasons, there are no merits in the case of the complainant. Therefore, it is liable to be dismissed.
4. To prove the case, on behalf of the complainant, she filed her affidavit and got marked Exhibits A1 to A5/A6 on the oher hand on behalf of the OP, they filed their evidence affidavit and got marked Exhibits B1 to B6.
5. Exhibit A1 is the Policy Bond, Exhibit A2 is the e-mail issued by the complainant to the Ops, dated 08-08-2012, Exhibit A3 is the Email issued by the complainant to the Ops, dated 22-09-2012, Exhibit A4 is the Email issued by the complainant to the Ops, dated 15-10-2012, Exhibit A5 is the Claim Form with enclosures submitted by the Complainant to the OP, dated 18-07-2012.
6. Exhibit B1 is the Policy terms and conditions, Exhibit B2 is the Repudiation Letter issued by the 1^st OP to the Complainant, dated 29-05-2013, Exhibit B3 is the Policy Bond in Duplicate, Exhibit B4 is the Claim Registration Form, dated 27-09-2012, Exhibit B5 is the Letter form 2^nd Op to 1^st OP, dated 10-03-2012, Exhibit B6 is the claim form dated 18-07-2012.
7. Both parties files their respective written arguments.
8. Heard arguments from both sides.
9. Now the point for determination to be determined in this case is;

Whether there is any deficiency of service on the part of the OPs and the Complainant is entitled to any reliefs asked for?

10.The true copy of the insurance policy Swasthya Bhima Policy along with terms and conditions is marked as Exhibit B1. The case of complaint in brief is that her daughter Nikhila is a student had some dental problem i.e., pain in the upper front region and contacted N.Prudvi Raj MDs for curing of the pain opted for surgery for permanent cure of the pain who directed the complainant to get her daughter to admit in Sunitha Nursing home for surgery under the supervision of qualified Anesthesia and as per the terms and conditions,  the complainant got her daughter and admitted in the Nursim Home on 30-06-2012 for dental surgery of “Impacted Upper Teeth” front region, and was discharged on 3-7-2012 which resulted expenditure of Rs.10,784/- for Surgery,  Medicines And Nursing Home charges. At this stage, it is relevant for us to know the definitions mentioned at 2.1.2. “Surgical Operation” means manual and/or operative procedures for correction of deformities and defects and  repair of injugires diagnosis and cure of diseases, relief of surrering and prolongation of life”

11.The 1^st contention of OP is that by drawing our attention to Exhibit B1 Exclusion No.4.7 of the policy with dental problem or surgery of any kind unless requiring hospitalization and also under Condtion No.5.2 of the above said Insurance Policy. This condition itself very clear that the claim can not be made unless the insured inpatient is hospitalized for getting the treatment done. In the present case, the insured patient was admitted in Sunitha Nursing Home as inpatient on 30-06-2012 and was discharged only on 7-7-2012 which is evident by the case sheet submitted by the complainant to the OP  along with claim form. The case of the OP is that after investigating case in nature, they came to a conclusion  that without any expert evidence to contradict the evidence placed by the complainant with the operation done to the compalinant’s daughter does not fall  in the ambit of the policy terms and condtions and refused to pay.

12.     The record clearly shows that the complainanat submitted all the record and case sheet showing the details of the surgery done to her daughter in Sunitha Nursing Home, is only way to get her pain removed completely and is a very essential thing to get removed from the continous problem to her teeth. Therefore,the complaint has filed the present complaint against both OPs for recovery of the  amount spent to her for getting treatment to her only daughter which is also covered under the insurance policy.

13.The contention of the complaint is that her claim is within the time and filed all the original bills, case summary and discharge sheet issued by the Nursing Home to enable the 1^st OP to settle the claim. Exhibit A2 is the Photostat copy of the claim form and case sheet and hospital bills and the courier receipt to show the dispatch and settlement  of the claims to the 2^nd OP as per the terms and conditions of the policy.  The record further shows as there is no response from any of the OP, the complainant has been requesting the 2^nd OP by way of e-mails marked as Exhibits to settle her claim at an early date. As per the policy terms and condtions, OP1 has to reimburse the expenditure incurred by the insured, the complainant  herein but inspite of 10 months laps, the OPs not settled the claim.

14.     The contention of the OP is that  the claim was made after lapse of 10 days i.e., after discharge of her daughter from nursing home. It is evident as per the counter averments made at para No.7 and also by their reply e.mail dated 28-09-2012 that  the complaint daughter was discharged on 3-7-2012 and the complainant submitted the mediclaim form on 18-07-2012 with all the requirements i.e., within the 15 days from the date of discharge from the hospital which is well within the time as per the policy condtion no.5.3 therefore, the contention of the OP that the claim is belated is incorrect. On a careful reading of the evidence let in by the complainant coupled with Exhibits marked on her behalf, we  are of the considered view that though the complainant made her claim within time and as per the terms and condtions of the policy, issued by Ops, they failed to reimburse amount incurred by the complainant which clearly indicates that there is a deficiency of service on the part of the Ops. Therefore, the claim made by the complainant deserves to be allowed.

15.     Now the question that comes up for consideration, at this stage of our discussion is, what is the rate of interest for which the Complainant is entitled.   The rate of interest claimed by the Complainant is 18% p.a.  This rate of interest claimed by the Complainant appear to be excessive, of course, it is a fact that the transaction covered by Ex.A1 is commercial in nature, but that does not and cannot mean to say that the Complainant is a licensed to claim interest @ 18% p.a. from the date of discharge i.e, on 03-07-2012.  But at the same time, it is imperative on our part to award a reasonable interest.   Having regard to all these facts and circumstances, we sincerely feel having considered the case on hand awarding of interest @ 9% p.a. would better serve the ends of justice.    Consequently, we proposed to fix at rate in question @ 9% p.a. on Ex.A 5 i.e., Claim Form in question.   Accordingly interest is ordered.

16.     Whether the Complainant is entitled for compensation of Rs.20,000/- is to be considered.   It appears as seen from the evidence of Complainant that the Complainant was compelled to approach the Opposite Parties and therefore experienced a lot of physical strain besides mental agony and financial loss. It is an un-disputed fact that the Opposite Parties did not refund the advance amount paid by the Complainant.   Naturally, that might have put the Complainant to suffer some mental agony besides physical stress and strain.   In this view of the matter, we sincerely feel that it is a fit case to award compensation.   But that does not and cannot mean to say that the Complainant claim for compensation is acceptable.    Having regard to all these facts and circumstances, we are of the considered opinion, award of compensation of 2,000/- would serve the ends of justice.   We therefore, proposed to award compensation of Rs.2,000 /-,  in the circumstances of the case on hand. Accordingly this point is answered.

17.     Before parting our discussion, it is incumbent and imperative on our part to consider the costs of litigation.    The Complainants ought not have to approach this Forum had his claim for payment of Rs.10,784/- or reliefs sought for have been honored by the Opposite Parties within a reasonable time and in view of the matter, the Complainant’s claim for costs deserves to be allowed.   In our considered and unanimous opinion awarding a sum of Rs.2,500/- as costs would appropriate and reasonable.   Accordingly costs are awarded.

18.     In the light of our discussion, referred supra, the complainant is entitled to receive the sum of Rs.10784/- together with subsequent interest @9% p.a., from 18-07-2012 till the date of realization, a compensation of Rs.2,000/- and also costs of Rs.2,500/- to the Complainant.

19.     In the result, this complaint is allowed in part, directing the OPs to pay an amount of Rs.10,784/-(Rupees Ten Thousand, seven hundred and eighty four only)  with interest @ 9% from 18-07-2012 till the date of realization, a compensation of Rs.2,000/- (Rupees Two thousand only) and costs of Rs.2,500/-(Rupees Two Thousand and five hundred only). Time for compliance, one month from the date of this Order.  

Dictated to the Stenographer, transcribed by him, corrected and pronounced by us in the open Forum, on this the   27^th day of May, 2015.                                   

 

Sd/-                                        Sd/-                                         Sd/-

LADY MEMBER                            MALE MEMBER                        PRESIDENT       

 

APPENDIX OF EVIDENCE

          For the Complainant:-

Exhibits	Date	Description	Remarks
A1		Policy Bond	Photocopy
A2	08-08-2012	Email issued by the complainant to the Ops	Computer Print Out
A3	22-09-2012	Email issued by the complainant to the Ops	Computer Print Out
A4	15-10-2012	Email issued by the complainant to the Ops	Computer Print Out
A5	18-07-2012	Claim form with enclosures submitted by the complainant to the OP	Photocopy

For the Opposite Parties:-  

Exhibits	Date	Description	Remarks
B1		Policy terms and conditions	Original
B2	29-05-2013	Repudiation Letter issued by the 1zst Op to the Complainant	Office Copy
B3		Policy Bond in duplicate	Office copy
B4	27-09-2012	Claim registration form	Original
B5	10-03-2012	Letter from 2nd Op to 1st OP	Office copy
B6	18-07-2012	Claim Form	Original

 

Sd/-                                         Sd/-                                         Sd/-

LADY MEMBER                            MALE MEMBER                        PRESIDENT