BEFORE THE A.P.STATE CONSUMER DISPUTES REDRESSAL COMMISSION :HYDERABAD

F.A.No.227/2007  against C.C.No.15/2006, Dist.Forum, West Godavari ,Eluru.            

Between:

Andhra Bank

Rep. by its Branch Manager,

Kovvur, West Godavari District.                             …Appellant/

                                                                          Opp.party no.1

        And

1.Smt. Nimmagadda Dhanalakshmi,

W/o.Pullarao, Hindu,

Aged about 46 years, occ:Housewife,

R/o.D.No.15-4-21, Bapuji Nagar,

Kovvur, West Godavari District.                                 …Respondent/

                                                                       Complainant

2. United India Insurance Co.Ltd.,

    Rep. by its Divisional Manager,

    Divisional office, IV, IInd floor,

    Porsnett Bhavan, Ramkoti ,

    Hyderabad.                                                    … Respondent/

                                                                           Opp.party no.2

Counsel for the Appellant        :   M/s.Ch. Shiva Reddy 

Counsel for the Respondents   :   M/s.K.L.N.Swamy-R1 

   CORAM: THE HON’BLE JUSTICE SRI D.APPA RAO, PRESIDENT,

SMT. M.SHREESHA, HON’BLE MEMBER

AND

                             SRI K.SATYANAND , HON’BLE MEMBER.

                   MONDAY, THE TWENTY SECOND  DAY OF FEBRUARY,

TWO THOUSAND TEN.

Oral Order (Per  Smt M.Shreesha, Hon’ble Member)

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            Aggrieved   by order in C.C.No15/2006, Dist. Forum, West Godavari, Eluru,  the opposite party no.1 preferred this appeal.

        The brief facts as set out in the complaint are that the complainant is having  an  S.B.Account with opposite party no.1  covered under Andhra Bank Arogyadhan Scheme  which is insured with  second opposite party.  On 25.4.2005  the complainant  felt severe pain in  her right side lower abdomen  and was admitted in   Global Hospital  where she was informed that  there is a cyst in the right ovary  and was advised to undergo surgery.  On 28.4.2005   she underwent surgery  and the cyst was removed for which she  spent Rs.32,446.17 ps.   towards medical treatment and Rs.9000/- towards incidental expenses.  Thereafter the complainant made a claim with the opposite party to reimburse the medical expenses . But inspite of repeated requests the opposite parties did not pay the claim amount. Hence the complaint seeking direction  to the  opposite parties to pay a sum of Rs.91,446.17 ps.  which also includes the compensation of Rs.50,000/-  and other costs. 

        Opposite party no.1 filed counter stating that  the  complainant is an account holder  of their  bank  and under the scheme she was insured with the opposite party no.2 insurance company and that the bank had forwarded all the claim papers with the relevant enclosures to the second opposite parties on 2.6.2005   but did  not receive any response. 

        The second opposite party filed its version   contending that the complainant  was having past history of surgery of vaginal Hysterectomy  i.e. right ovarian cyst multiloculated adherent to lateral pelvic  wall and sigmoid colon  which would be developed over a period of above 3 months and its adhesions to pelvic wall and colon is due to previous surgery which was not revealed at the time of taking policy which was confirmed by the case sheet of Global Hospital, Hyderabad.   The opposite party submits  that the complainant holding the policy since 15.2.2005   and date of admission into the hospital was 27.4.2005 within 3 months and as per  clause 4.1 of the   Stands Medi claim policy any pre existing disease  within 3 months of the inception of the policy, the claim will not be entertained   and the complainant by suppressing her previous  obtained the policy. Hence  the opposite party  submits that there is no deficiency of service  and   prayed for dismissal of the complaint 

        The  District Forum based on the evidence adduced i.e. Exs.A1 toA11 and B1 to B10 allowed the complaint directing the opposite parties  to pay  an amount of Rs.32,446/- towards medical expenses and also pay Rs.5000/-  towards compensation along with costs of Rs.500/- to the complainant  within one month from the date of the order.

        Aggrieved by the said order  the opposite party no.1 preferred this appeal.

        The facts not in dispute are that the complainant is having an S.B. account  in the appellant opposite party no.1 bank and is covered under Andhra Bank Aroghyadhan scheme  and the said scheme is insured with  opposite paprty no.2 insurance company.  It is the case of the complainant that on 26.4.2005  she felt  severe pain in the  right  side lower abdomen  and on examination she was informed that she has a cyst  in right ovary  and thereafter she underwent surgery in Global hospital and the cyst was removed on 28.4.2005   and she submits that she spent Rs.32,446.17 ps.  towards medical treatment and Rs.9000/- towards   incidental charges.  It is the case of the opposite party  no.1that they have  submitted all the claim papers on 2.;6.2005   along with all relevant papers to  opposite party no.2 insurance company for settling the claim , but opposite partyno.2 did not pay the claim amount .  As seen from the record opposite party no.2  had repudiated the claim on the ground that there is pre existing  disease  for which the complainant had  contended that she underwent Vaginal hysterectomy in the year 1993   and that the  present history was due to formation of cyst in the ovary  and that the cyst is recently formed just prior to the surgery and the same was removed and this has nothing to do with the hysterectomy  which she underwent in the year 1993 whereas the cyst was removed on 28.4.2005   almost 12 years later .    

However the brief point   that falls for consideration in this appeal is whether the appellant/opposite party no.1 is liable to pay the insurance claim amount?

        Taking into consideration that the appellant/opposite party no.1 is only a facilitator and forwarded the claim forms on 2.6.2005   along with the relevant enclosures to opposite party no.2  insurance company, we are of the considered view  that no deficiency in service can be attributed to appellant/opposite party  no.1 in the instant case .  It is also not the case of opposite party no.2 insurance company that the claim was repudiated because  of delay in submission of claim forms or because of any deficiency attributed to opposite party no.1.  The opposite  party no.2 repudiated the claim solely on the ground of suppression of pre-existing disease.  To reiterate, the role of the appellant/opposite party no.1 herein is only that of  a facilitator for which they cannot be made liable to pay the claim amount.  Hence we are of the considered view that no deficiency in service can be attributed  to   appellant/opposite party no.1 and therefore the order of the District Forum is set aside with respect to appellant/opposite party no.1 only, while we confirm the rest of the order of the District Forum. 

In the result this appeal is allowed and the order of the District Forum is set aside with respect to the liability of appellant/opposite party no.1 only while we confirm the rest of the order of the District  Forum. No costs.

                                                                        PRESIDENT

                                                                        MEMBER

                                                                        MEMBER

                                                                        Dt.22.2.2010

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