BEFORE THE DISTRICT CONSUMER FORUM AT NALGONDA
PRESENT: SRI MAMIDI CHRISTOPHER,
PRESIDENT.
SMT.S.SANDHYA RANI,
FEMALE MEMBER.
SRI K.VENKATESHWARLU,
MALE MEMBER.
. . .
WEDNESDAY, THE TWELFTH DAY OF FEBRUARY, 2020
CONSUMER COMPLAINT No. 34 OF 2014
Between:
1. G.Mehar Baba S/o G.Peda Narsaiah, Aged: 32 years, Occ: Business,
2. G.Peda Narsaiah S/o Buchaiah, Aged: 69 years, Occ: Business,
Both R/o Near Kanakadurga Temple, Ramagiri, Nalgonda Town
and District.
…COMPLAINANT.
]
AND
1. New India Assurance Co.Ltd., Rep.by its Authorized Signatory,
Regd. & Head Office: New India Assurance Building, 87, M.G Road,
Fort, Mumbai- 400001.
2. New India Assurance Co.Ltd., Hyderabad Regional Office,
Rep.by its Authorized Signatory, 5th Floor, Surya Towers,
Sardar Patel Road, Secunderabad-500 003.
3. The New India Assurance Co.Ltd., Divisional Office,
2nd Floor, Sangamitra Bank Complex, Prakasham Bazaar,
Nalgonda–508001.
…OPPOSITE PARTIES.
This complaint coming on before us for final hearing, in the presence of Sri G.C.Narsaiah, Advocate for the Complainants, and Sri A.Suresh Babu, Advocate for the Opposite Parties, and on perusing the material papers on record, and having stood over for consideration till this day, the Forum passed the following:
ORDER OF THE FORUM DELIVERED
BY SRI MAMIDI CHRISTOPHER, PRESIDENT
1. This complaint is filed by the Complainant Under Section 12 of Consumer Protection Act, 1986 against the Opposite Parties, to direct the Opposite Parties to pay an amount of Rs.47,354/- with interest and also to pay Rs.40,000/- towards mental agony and legal charges along with costs, for deficiency in services on the part of the Opposite Parties.
Contd…2
-2-
2. The facts leading to the filing of this complaint as follows:
The Complainant No.1 is the son of Complainant No.2. The Complainant No.2 went to Yashoda Hospital, Hyderabad on 06/06/2013 due to ill health and joined in the said hospital as in-patient, vide I.P.No.201067, wherein a room was allotted to him and he was undergone surgery on 08/06/2013. During the period of hospitalization, an amount of Rs.74,754/- was spend by the Complainants towards the treatment of the said ailment in the hospital. The said amount incurred by the Complainant No.2 was paid to the hospital from his pocket. The Complainant No.2 was discharged from the hospital on 10/06/2013. The said hospital authorities have issued bill for the above said amount towards operation and medical expenditure etc. and also issued valid receipts for the payment made by Complainant No.2.
3. The Complainant No.1 had obtained a Mediclaim Policy-2007 (Hospitalization Benefit Policy), vide Policy No.613200/34/12/01/
00000248 from the Opposite Parties by paying necessary premium for three persons, i.e. for himself and his parents [i.e. Complainant No.2 and mother of Complainant No.1, i.e. wife of Complainant No.2]. The sum assured of the policy is Rs.1,00,000/- and policy covers from 27/09/2012 to 26/09/2013 and it covers Rs.1,00,000/- for each member including Smt.Vijaya. The Complainant No.1 paid premium amount as allowed by Opposite Party No.3.
4. After discharge of Complainant No.2 from the hospital, the original medical bills and original policy have been submitted by the Complainants to the Opposite Party No.3 for processing and for
Contd…3
-3-
payment of amounts under the said Mediclaim Insurance Policy. The Opposite Parties have cleared the bills and sent only an amount of Rs.27,400/- out of Rs.74,754/- by disallowing of Rs.47,354/-. In this regard, the Complainants submitted that at time of issuing the policy, the Opposite Parties have furnished a Mediclaim Insurance Policy Prospectus, which is entirely different as that of newly supplied prospectus by the Opposite Party No.3 along with its reply to their legal notice, dated 16/09/2013. The Opposite Parties also furnished the claim process sheet along with fresh prospectus. The so-called fresh prospectus is different from that of earlier prospectus supplied to Complainant No.1. The terms and conditions of the new prospectus disclose that the claim is eligible for room rent up to Rs.1,000/- per day [1% of total sum assured]. It is stated that there are no reasons for disallowing the amounts in respect of item No.2.3 and 2.4, such as surgeon, Anaesthetist, Medical Practitioner, Consultants and Specialist Fee, X-Ray and other medical expenses relating to the treatment, laboratory/diagnostic in the claim process sheet furnished by Opposite Party No.3. The Opposite Parties failed to arrange the policy scheme benefits and not rendered proper services in payment of policy amount and furnished wrong information regarding eligibility of the claim. The claim of the Complainants are denied by the Opposite Party No.3, for which the Opposite Parties are liable to pay the disallowed amount and also compensation towards monetary and mental loss caused to the Complainants.
5. The Opposite Parties have contested the complaint and the Opposite Party No.3 filed its counter/written version and the same is adopted by Opposite Parties No.1 and 2. The Opposite Parties
Contd…4
-4-
admitted that the issuance of the said policy by Opposite Party No.3, but it is applied subject to terms and conditions of the clauses applicable in the said Mediclaim Policy. It is also admitted that the ailment and treatment taken by the Complainant No.1’s father, i.e. Complainant No.2 in Yashoda Hospital, Hyderabad and also stated that they may have incurred Rs.74,754/- towards treatment.
6. The Opposite Party No.3 has denied the Ex.A-1 terms and stated that as per the Mediclaim Insurance Policy, 1% of the sum assured comes to Rs.1,000/- would be considered towards room rent in case of hospitalization apart from other applicable clauses. It is further contended by the Opposite Party No.3 that they have settled the claim as per the guidelines of the said Mediclaim Policy terms and conditions with clauses, upon the recommendation by the Third Party Administrator only and as such it is stated that there was no deficiency in service on the part of the Opposite Party No.3. The Opposite Party No.3 further alleged that the complaint is not maintainable and deserves to be dismissed on the basis of jurisdiction and also to implead the Third Party Administrator namely; M/s GHPL [Good Health Plan Limited] Company [TPA] which is necessary party for adjudication. The Opposite Party No.3 in this regard has stated that the claim was processed and advised by the “Third Party Administrator of Insurance” for processing insurance claims and as per its advice the Complainants claim has been paid finally by the Opposite Party No.3.
7. The Complainant No.1 has filed his affidavit along with complaint which discloses the same facts mentioned in the complaint. The Complainants not filed any evidence affidavit, but they have filed
Contd…5
-5-
documents to support their claim, which are marked as Exs.A-1 to A-4. The Opposite Party No.3 filed his proof affidavit to defend their case and also filed documents marked as Exs.B-1 to B-6.
8. The pleadings of the parties, gave rise to the following points for consideration and determination of the matter.
9. The points for consideration are:
- Whether this Forum have jurisdiction to entertain the
present complaint?
- Is it M/s GHPL company is necessary party to the
proceedings for adjudication?
- Is there any deficiency in service on the part of the
Opposite Parties in not allowing the entire claim amount
of Rs.74,754/-?
- Whether the Complainant are eligible for Rs.47,354/-?
- Is there any monetary loss or mental agony caused to the
Complainants?
6) If so, to what extent?
10. POINT No.1:
The subject matter of the complaint is deficiency in service on the part of the Opposite Parties, i.e. New India Assurance Company Limited. The Complainant No.1 is insured person and the Complainant No.2 is also a beneficiary under the said policy obtained by Complainant No.1. On the failure of payments claimed by the Complainants by the Opposite Parties, the complaint has been filed. The allegation of the Opposite Parties that the Complainants not chosen to opt to approach the Insurance Ombudsman, is not at all tenable as the Complainants being consumers have every right to approach the Consumer Forums for redressal of their consumer dispute. As per Section-3 of the Consumer Protection Act, 1986, the
Contd…6
-6-
Complainants can opt any remedy and to seek redressal available to them. The Consumer Protection Act provides additional remedies to the consumers, as such this Forum has rightly entertained the complaint and accordingly the Point No.1 is decided in favour of the Complainants.
11. POINT No.2:
The subject policy had issued by the New India Assurance Company Limited, i.e. Opposite Party No.3. The said Opposite Party No.3 also answered/replied to the legal notice of the Complainants under Ex.A-2. The said reply notice, i.e. Ex.A-2 does not disclose the information regarding the claim was processed by Third Party Administrator. The recitals of the said Ex.A-2 shows that the claim was processed under the prospectus of Mediclaim-2007 Policy, but nowhere it is mentioned that the claim was processed by the said Third Party Administrator. It appears that Opposite Party No.3 is responsible person to decide to allow the claim. Though the said Third Party Administrator processed the claim, ultimately it should be verified by Opposite Party No.3 and to clear the claim being insurance company which issued the policy. It is also seen from the so-called Mediclaim Policy-2007 prospectus supplied to the Complainants along with its reply by the Opposite Party No.3 that under the clause 11.0, i.e. notice of claim, it is mentioned as “preliminary notice of the claim with particulars of the policy, claim etc. should be given to the Company/ TPA within seven days from the date of hospitalization, in respect of reimbursement of claims. It is also seen under the same clause of the said prospectus that final claim along with hospital original bills, cash memos and documents listed in the claim form
Contd…7
-7-
should be furnished to the policy issuing office/TPA not later than 30 days of discharge from the hospital. It is further noticed from the same prospectus that the said TPA may be for procedure for availing cashless facility, but it is not the case of cashless facility in this matter, it is only a reimbursement. It is, therefore, the claim should be decided by the Opposite Parties and as such the Third Party Administrator is not a necessary party and as such there is no legal necessity to add the said Third Party Administrator as alleged by the Opposite Party No.3. The Point No.2 is decided accordingly.
12. POINTS No.3 & 4:
There is no controversy in respect of issuance of policy and submission of medical bills for Rs.74,754/- towards payment of claim to the Opposite Parties. The controversial factor is only about non-allowing of Rs.47,354/- out of Rs.74,754/. It is pertinent to discuss about so-called terms and conditions of prospectus which was furnished to the Complainant No.1 at the time of obtaining the policy and also the prospectus supplied by the Opposite Party No.3 along with its reply notice. In this regard, it can be seen that there are some variations under the clauses. The Complainant No.1 claims as per the prospectus, i.e. Ex.A-1, wherein it is not found the room rent and also other particulars. Ex.A-2 shows that the policy sum assured of Rs.1,00,000/- covers the subject policy and the Complainant No.2 was eligible for room rent of Rs.1,000/- per day. On the basis of 1% of sum assured excluding cumulative bonus, Intensive Care Unit [ICU] expenses of 2% on sum assured which comes to Rs.2,000/- and the amounts and the amounts payable under Heads of Clause-2.3 and 2.4 as per the Opposite Party No.3’s prospectus shall be limited to the
Contd…8
-8-
charges applicable to the entitled category. It is also seen from Ex.A-2 that if in any case insured opts for a room with rent higher than the entitled category as under Clause-2.1, the charges payable under Clauses-2.3 and 2.4 of prospectus of mediclaim-2007 shall be limited to the charges applicable to the entitled category. On the whole, it is understood that the claim was not allowed fully by the Opposite Party No.3 on the basis of room rent. Mere saying that the Complainants are not eligible for the room rent as claimed by them as per the medical bills. Though it is mentioned in Ex.B-3 under Clause-2.1 that the room, boarding and nursing expenses as provided by the Hospital not exceeding 1% of the sum assured including cumulative bonus per day or actual amount, whichever is less and other facilities will be calculated on the basis of room rent. It could be seen from the second page of Ex.B-1 that “this policy is subject to Mediclaim Policy (2007) clause as attached”. It is observed, on this point that one cannot read and understand the said information which was incorporated in small letters in the policy. Moreover, there is no evidence that the Opposite Parties furnished the said Mediclaim Policy-2007 clauses along with policy, which is required to be furnished by Opposite Party No.3. In the absence of such information/evidence, the consumer or the Claimant of the insurance company will be faced inconvenience and they could not follow correct instructions and particulars of claim which they are eligible to claim under the Insurance Policy, which is nothing but deficiency in providing services to the customers of insurance policy holders. The present case also, the one of the disputable factor is also regarding terms and conditions, lack of information, regarding room rent etc. That the parties to the contract of ifnsurance are governed by the terms and conditions of the insurance policy issued at
Contd…9
-9-
the time of such contract and it is the duty of the insurance company to furnish correct details regarding the terms and conditions at the time of issuance of policy. The complete details with regard to the policy issued by the insurance company were sent to the insured. Therefore, it is clear that the insured was made aware of the terms and conditions governed the said policy. In this case, the Complainants/insured are not furnished the exact terms and conditions, i.e. Mediclaim Policy-2007 Prospectus and they are not aware of the terms and conditions. If it would have been furnished, there will be no problem to arrange his own facilities in the hospital and they may get arrangements as per the convenience of the terms and conditions. It is, therefore, observed that the Opposite Party No.3 has failed to provide correct information in providing correct prospectus at the time of issuance of policy and on the basis of new prospectus not allowing the claim made by the Complainants, for which they are liable to pay at least of the amount which is not approved by Opposite Party No.3 which comes around Rs.23,670/- out of Rs.47,354/-. In view of aforesaid discussion, this Forum arrive conclusion that there is unfair on the part of the Opposite Parties, for which they are liable to pay the said amount to the Complainants. It is, thus, this Forum hold that the Opposite Parties shall liable to pay Rs.23,670/- to the Complainants towards bill amount.
13. POINTS No.5 & 6:
The amount of Rs.40,000/- as claimed by the Complainants towards mental agony and legal charges cannot be considered fully as there is no evidence fully how the Complainants suffered mental agony. However, they may be disturbed with some sort of tension in
Contd…10
-10-
not settling full claim and due to delay and forced them to approach the Forum, as such we hold to consider to an extent of Rs.10,000/- towards mental agony if any suffered by them, which to be paid by the Opposite Parties to the Complainants. It is, thus, the Points No.5 and 6 decided in favour of the Complainants partly.
In the result, the complaint is allowed in part, directing the Opposite Parties to pay to the Complainant No.1, an amount of Rs.23,670/- (Rupees Twenty Three Thousand Six Hundred and Seventy only) towards Mediclaim bills along with interest at the rate of 9% per annum from the date of filing of the complaint, i.e. 11/06/2014 till realization, a sum Rs.10,000/- (Rupees Ten Thousand only) towards compensation for mental agony and a sum of Rs.2,000/- (Rupees Two Thousand only) towards costs of the legal charges. Time for compliance one month from the date of receipt of this order.
Dictated to Steno-Typist, transcribed by him, corrected and pronounced by us in the open Forum on this 12th day of February, 2020.
FEMALE MEMBER MALE MEMBER PRESIDENT
APPENDIX OF EVIDENCE
WITNESSES EXAMINED
For Complainants: For Opposite Parties:
Affidavit of the Complainant No.1. Affidavit of Opposite Party No.3.
EXHIBITS MARKED
For Complainants:
Ex.A-1: Prospectus of Mediclaim Insurance Policy.
Ex.A-2 Dt.04/10/2013 O/c of Reply Notice, issued by Opposite
Party No.3 to the counsel for the
Complainants along with Prospectus of
Mediclaim Policy (2007).
Contd11
-11-
Ex.A-3 Xerox copy of Claim Process Sheet.
Ex.A-4 Xerox copy of description/statement of
claim amount, issued by Yashoda Hospital,
Secunderabad.
For Opposite Parties:
Ex.B-1 Dt.27/09/2012 Attested copy of Policy Schedule of
Mediclaim Policy-2007 along with
Collection Receipt-cum-Adjustment Voucher.
Ex.B-2 Dt.15/07/2014 Attested copy of details of payment towards
full and final settlement for the Mediclaim
bills along with Claim Process Sheet.
Ex.B-3 Prospectus of Mediclaim Policy (2007).
Ex.B-4 Dt.27/09/2012 Attested copy of Policy Schedule of
Mediclaim Policy-2007.
Ex.B-5 Attested copy of Prospectus of Mediclaim
Policy (2007).
Ex.B-6 Dt.15/07/2014 Attested copy of details of payment towards
full and final settlement for the Mediclaim
bills along with Claim Process Sheet.
PRESIDENT
DISTRICT CONSUMER FORUM
NALGONDA
