Andhra Pradesh

Visakhapatnam-II

CC/312/2011

Pinisetti Rambabu - Complainant(s)

Versus

Star Health and Allied Insurance Company Limited - Opp.Party(s)

Sontyana Mohan Rao

25 May 2015

ORDER

 Reg. of the Complaint: 22-08-2011

                                                                                                                                      Date of Order:25-05-2015

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

                                            

 

MONDAY, THE 25^TH DAY OF MAY, 2015

CONSUMER CASE NO.312/2011

 

BETWEEN:

Sri Pinisetti Rambabu S/o Sri P.Paparao,

Hindu, aged 38 years, Private Employee,

Residing at D.No.22-51-38, Town Hall Road,

Visakhapatnam-530 001.

…Complainant

AND:

 

1.M/S Star Health and Allied Insurance Co., Ltd.,

Rep. BY its Branch Manager, Flat No.401, V.R.C.Complex,

Railway Station Road, Dwarakanagar, Visakhapatnam-530 016.

 

2.M/s Star Halth and Allied Insurance Co., Ltd.,

Rep. by its Manager, KRM Centre, VI Floor, No.2,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 

Harrington Road, Chetpet, Chennai-600 031.

…Opposite Parties

This case coming on 12-03-2015 for final hearing before us in the presence of SRI SONTAYANA MOHANA RAO, Advocate for the Complainant, and of SRI K.A.PRAKASH, Advocate for the 1^ST & 2^nd Opposite Parties, 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, directing them to pay an amount of Rs.2,93,500/- with interest @ 24% p.a., from the date of accident i.e., 21-01-2011 till the date of realization and to pay Rs.3,00,000/- towards compensation, Rs.25,000/- towards costs.
2. The case of the complainant in brief is that he has taken Medi claim Insurance Policy by paying an amount of Rs.4,125/- for which a policy bond was issued and on intervening night of 20/21-01-2011, he met with an accident and immediately, he was shifted to KGH, Visakhapatnam because of the non availability of beds in the network hospitals of the Ops and took treatment in King George Hospital till 28-01-2011 and for better treatment, he was admitted in Aditya Multicare Hospital, Visakhapatnam till 20-02-2011 as a result, he incurred an expenditure of Rs.2,93,500/- which is also his case athat he made a claim with the OP with the relevant records, but they repudiated his claim for no justifiable reason. Hence, this complaint.
3. The case of the Ops, admitted the complainant obtained policy and contended that the policy was cancelled by them on 7-7-2011 on coming to know that the claim made by the petitioner is fabricated. Immediately on receipt of intimation about the accident and treatment, they requested the complainant to submit all the relevant papers to settle the claim but without enclosing the relevant documents, he sent the papers  and that they intimated about the closing of policy. It is also their case that on receipt of the claim, they appointed an investigator to verify the genuineness of the claim who after investigation submitted report on 27-02-2011 informing them that AMC Hospoital where the complainant claims to have undergone the treatmet was not functioning at all from the last 1 year and it was closed. It is also their case that there were no fracture injury on the head of the complaint and there is nothing on record to show that there was a fracture as alleged by the complainant and there was no necessity for the complainant to undergo any such treatment and all the bills, receipts and the case summary were fabricated by the complainant to suit his case.
4. That as the claim of  the complaint is false and fraudulent, they were forced to repudiate the claim and that the complainant has not come to this forum with clean hands. For these reasons, the complaint is liable to be dismissed.
5. To prove the case on behalf of the complainant, he filed his sworn affidavit and got marked Exhibit A1 to A15. On the otherhand, on behal of the OPs, OP2 filed his affidavit and got marked Exhibit B1 to B5.
6. Exhibit A1 is the Medi Classic Insurance Policy dated 22-11-2010, Exhibit A2   is the Discharge form issued by the KGH, Visakhapatnam, dated 28-01-2011, Exhibit A3 is the Discharge Certificate issued by the Aditya Multicare Hospital, dated 20-02-2011, Exhibit A4 is the Bill cum Receipt No.4 for Rs.2,90,400/- dated 20-02-2011, Exhibit A5 is the Reciept No.546 issued by the Sun Diagnostics, Visakhapatnam for Rs.2,090/- dated 29-01-2011, Exhibit A6 is the Receipt No.550 isued by the Sun Diagnostics, Visakhapatnam for Rs.360/-, Exhibit A7 is the Receipt no.557, dated 06-02-2011, Exhibit A8 is the Receipt No.583, dated 08-02-2011, Exhibit A9 is the Letter from the Ops addressed to the complainant, dated 14-02-2011, Exhibit A10 is the Claim form for medical insurance, dated 02-03-2011, Exhibit A11 is the Letter addressed by the complainant to the 1^st OP, dated 17-05-2011, Exhibit A12 is the letter addressed by the complainant to the 1^st OP, dated 20-05-2011, Exhibit A13 is the Letter addressed by the wife of the complainant to the 1^st OP, dated 21-05-2011, Exhibit A14 is the Letter addressed by the wife of the complainant to the 1^st OP, dated 21-05-2011 and Exhibit A15 is the Letter addressed by the father of the complainant to the 1^st OP, dated 26-05-2011.  
7. Exhibit B1 is the Investigation Report, dated 06-06-2011, Exhibit B2 is the Leter addressed by the OP to the complainant, dated 12-05-2011, Exhibit B3 is the Letter addressed by the OP to the complainant , dated 09-06-2011, Exhibit B4 is the Letter addressed by the OP to the complainant, dated 07-07-2011 and Exhibit B5 is the City Edition of Eenadu News Paper of Visakhapatnam dated 28-06-2011.
8. Exhibit C1 is the Case Record.
9. Both parties filed their respective written arguments.
10. Heard oral arguments from both sides.
11. 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?

12. The Opposite Party admitted the issuance of policy but specifically contended that there is no record to show that the complainant took treatment for the alleged injuries sutained by him either in the KG Hospital or in the Aditya Medicae Hospital. To prove the same, the complainant relied upon Exhibit A1 to A10.  Exhibit A2 is the discharge form issued by KGH.  Exhibit A2 reveals that the complainant approached the KGH Authotires on 21-01-2011 since he was alleged to sustain by head injury  due to skid from bike.  Exhibit  A2 shows that he was treated as out patient till 27-01-2011 and he was advised on that day to review the same after 15 days and on 11-02-2011 when he approached the authorities, they prescribed some medicines holding no fracture injury etc., Exhibit A3 is the discharge certificate alleged to have been issued by Aditya Multi Care Hospital. Exhibit A4 to Exhibit A8 are the receipts stated to have been paid by the complainant to the hospital authorites.  Admittedly, either the affidavit of KGH Authoriites or Aditya Medicare Hospital were filed by the complainant evidencing his treatment expenditure as contended by him. The contenton of the complaint is that he sustained facrture and took treatment at KGH for his head injury. But no proof is filed evidencing the same. If really the complainant met with accident, the moment he approached the KGH Authorties, they will refer the compliant to police by intimating the accident. But, they did not do so. On the other hand, Exhibit A2 shows  that the complainant was treated as out patient and no  fracture was sustained by him as contended by the complainant. On scruitiny of Exhibit A2 coupled with the absence of filing evidence affidavit of any hospital authorities concerned, it dcan be held that the contention of the complainant that he met with accident as a result he sustained fracture is not at all believable.
13. Now coming to Exhibit A3 to A8 the discharge certificate and police receipts, stated to have been issued  by Aditya Medicare Hospital, the complainant is not either summoned the relevant hospital authorites nor filied the evidence affidavit by the concerned Manager or Medical Officer who alleged to have treated the complainant.  I do not understand when KGH Authortiies  thenselves endorsed in Exhibit A2 that the complainant has not sustained any fracture what made him to approach Aditya Medicare Hospital for further treatment. It is the specific case of the Ops, that the correspondence between the complainant and themselves and the report of the investigator along with all the enclosers which are marked as Exhibits B series clearly establish that the complainant failed to produce the X-ray sheet to prove the alleged fracture sustained by him. In its absence, the contention of the complainant that he sustained fracture and took treatment can not be said to be proved and finally contended that the documents A3 to A8 were all not genuine and finally contended that Aditya Medicare Hospital was not at all genuine at the relevant period. The report of the investigator Exhibit B1 dated 6-6-2011, the efforts made by him to contact the person in charge Exhibit B1 shows for verifrication of the records to ascertain the genuineness of the documents filed by the complainant.  The report further shows that the accident and identity of Aditya Medicare Hospital is doubtful. The report further shows the invenstigator made an attempt to meet the doctors who were obliged to be the consultant doctors for the said hospital were either not available or disclosed that  they were not the constulatnts for the said hospital. The said fact also shows that the documents filed by the complainant are not genuine and it appears that they were filed for the purpose of this claim.
14. The letter addressed by the OPs dated 9-6-2011 vide Exhibit B3 and 7-7-2011 vide Exhibit B4 reveals in spite of addressing the letter by them, the complainant did not furnish the relevant record to settle the claim which forced them the claim made by the complainant is not genuine.
15. On  a careful reading of the documents submitted by both sides,  i.e., Exhibits concerned, we are of the considered view that the complainant failed to establish his case as contended by him. Therefore, the claim of the complaint deserves to be dismissed.
16. In the result, this  complaint is dismissed. No costs.

Dictated to the Stenographer, transcribed by him, corrected and pronounced by us in the open Forum, on this the  25^th day of May, 2015.                                   

 

Sd/-                                        Sd/-                                         Sd/-

LADY MEMBER                            MALE MEMBER                        PRESIDENT       

 

APPENDIX OF EVIDENCE

  For the Complainant:-

Exhibits	Date	Description	Remarks
A1	22-11-2010	Medi Classic Insurance Policy Schedule Medi Claim Policy Schedule	Original
A2	28-01-2011	Discharge form issued by the KGH, Visakhapatnam	Photocopy
A3	20-02-2011	Discharge Certificate issued by the Aditya Multicare Hospital	Photocopy
A4	20-02-2011	Bill cum Receipt bearing No.4 issued by the Aditya Multicare Hospital	Photocopy
A5	29-01-2011	Receipt No.546 issued by the Sun Diagnostics	Photocopy
A6	01-02-2011	Receipt bearing No.550 issued by the Sun Diagnostics	Photocopy
A7	06-02-2011	Receipt No.557 issued by the Sun Diagnostics	Photocopy
A8	08-02-2011	Receipt No.583 issued by the Sun Diagnostics	Photocopy
A9	14-02-2011	Letter from the Ops addressed to the Complainant	Photocopy
A10	02-03-2011	Claim form for Medical Insurance	Photocopy
A11	17-05-2011	Letter addressed by the complainant to 1st OP	Photocopy
A12	20-05-2011	Letter addressed by the complainant to 1st OP	Photocopy
A13	21-05-2011	Letter addressed by the wife of the complainant to 1st OP	Photocopy
A14	21-05-2011	Letter addressed by the wife of the complainant to 1st OP	Photocopy
A15	26-05-2011	Letter addressed by the father of the complainant to 1st OP	Photocopy

 

For the Opposite Parties:-  

Exhibits	Date	Description	Remarks
B1	06-06-2011	Investigation Report	Original
B2	12-05-2011	Leter addressed by the OP to the complainant	Office Copy
B3	09-06-2011	Letter by the Ops addressed to the complainant	Office Copy
B4	07-07-2011	Letter by the Ops addressed to the Complainant	Office Copy
B5	28-06-2011	City Edition of Eenadu News Paper, Visakhapatnam	Photostat

 

Sd/-                                        Sd/-                                         Sd/-

LADY MEMBER                            MALE MEMBER                        PRESIDENT