Date of filing:17.8.2013
Date of Disposal:6.2.2014
BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-II::
VIJAYAWADA, KRISHNA DISTRICT.
Present: SRI A. M. L. NARASIMHA RAO, B.SC., B. L., PRESIDENT
SMT N. TRIPURA SUNDARI, B. COM., B. L., MEMBER
SRI S.SREERAM, B.COM., B.A., B.L., MEMBER
THURSDAY, THE 6TH DAY OF FEBRUARY, 2014.
C.C.No.147 OF 2013.
Between :
Abothula Venkateswara Rao, S/o Srinivasa Rao, Hindu, 41 years, employee, R/o D.No.8-28-19, Wynchipeta, Vijayawada – 1.
….. Complainant.
And
1. Star Health and Allied Insurance Company Limited, Rep., by its Authorized Signatory, New Tank Street, Valluarkottam High Road, Chennai.
2. The Manager, Star Health and Allied Insurance Company Limited, D.No.40-1/1-17, Adaiah Nagar, Opp:Chennupati Petrol Bunk Road, Mogalrajapuram, Vijayawada - 520 010.
…..Opposite Parties.
This complaint is coming before us for final hearing on 23.1.2014 in the presence of Sri S.S.C.Bose, Counsel for complainant and Sri N.Sridhar, Counsel for opposite parties and upon perusing the material available on record, this Forum delivers the following:
O R D E R
(Delivered by Hon’ble Member Smt N. Tripura Sundari)
This complaint is filed under Section 12 of the Consumer Protection Act, 1986.
1. The averments of the complaint are in brief:
The complainant obtained family health optima Insurance Policy from the opposite parties for a sum of Rs.3 lakhs covering the risk to himself and his family members for a period of one year commencing from 23.11.2012 to 22.11.2013. During the subsistence of the said policy the complainant underwent Ratina Detachment surgery and incurred an expenditure of Rs.50,211/-. The complainant informed the said fact to the opposite parties and submitted claim form along with necessary documents on 15.4.2013. On scrutiny of the said documents the opposite parties sanctioned a sum of Rs.22,211/- only to the complainant on 11.6.2013 and further informed that the maximum amount payable is Rs.20,000/- only. The said restriction clause was not mentioned anywhere in the terms and conditions of the policy. Therefore the opposite parties are liable to pay the balance amount of Rs.28,000/-. The complainant made several representations to the opposite parties to consider his claim and pay the balance amount. But the opposite parties did not consider his genuine request. Thus, the complainant got issued a legal notice dated 18.7.2013 demanding the opposite parties to pay the balance amount. The opposite parties received the said notice and kept quiet, which amounts to deficiency in service. Hence the complainant is constrained to file this complaint against the opposite parties praying the Forum to direct the opposite parties to pay a sum of Rs.28,000/- with interest at 12% per annum from 11.6.2013 to pay Rs.25,000/- towards compensation for mental agony and to pay costs of Rs.5,000/-.
2. Opposite parties 1 and 2 filed their Vakalats and no version, affidavit and documents are filed on behalf of them.
3. On behalf of the complainant he filed his affidavit and got marked Ex.A.1 to Ex.A.13.
4. Heard and perused.
5. Now the points that arise for consideration in this complaint are:
1. Whether there is any deficiency in service on the part of opposite parties in not
settling the insurance claim of the complainant?
2. If so is the complainant entitled for any relief?
3. To what relief the complainant is entitled?
POINTS 1 AND 2:-
6. on perusing the material on hand the complainant obtained family health optima insurance policy from the opposite parties for a sum of Rs.3 lakhs for covering the risk to himself and his family members under Ex.A.1 for a period of one year commencing from 23.11.2012 to 22.11.2013. While the policy is in force the complainant underwent Ratina detachment surgery on 6.4.2013. It is evident from Ex.A.2 medical certificate given by the treating doctor Ajit Babu. The complainant submitted claim form for the said surgery amount of Rs.50,211/- with necessary documents Ex.A.3 investigation report of I-Max diagnostic centre Ex.A.4 cash receipts for surgery cost and medical bills dated 6.4.2013 issued by Centre for Sight Hyderabad and Ex.A.5 medical prescription issued by the doctor of centre for sight hospital for the use of medicines to right eye which was operated. Ex.A.6 is discharge summary issued by the said hospital dated 6.4.2013. Ex.A.7 is letter from opposite parties dated 9.5.2013 requesting the complainant to send original documents. The complainant sent reply to Ex.A.7 under Ex.A.8 dated 23.5.2013 informing that he had sent all the documents as provided by the hospital authorities. The opposite parties sanctioned a sum of Rs.22,211/- under Ex.A.9 dated 11.6.2013 stating that procedure charges allowed for bill No.727 surgery charges Rs.20,000/- reasons that maximum Rs.20,000/- only payable and medical charges for rs.511/- and pre hospitalization charges Rs.1,700/- total amount of Rs.22,211/-. The complainant sent letter to opposite parties Ex.A.10 dated 28.6.2013 requesting to sanction the remaining balance of Rs.28,000/- to him. But as there is no response he got issued a legal notice dated 18.7.2013 to the opposite parties demanding to pay the balance amount of Rs.28,000/- to him otherwise he will proceed to the court of law. The opposite parties received the said notices under Ex.A.12 and Ex.A.13.
7. On perusing the said documents in Ex.A.1 we noticed that the opposite parties mentioned that the insurance under this policy is subject to conditions clauses, warranties, exclusions etc; attached. But the complainant did not file the terms and conditions attached to the policy. So also the opposite party did not respond to the case of the complainant in the Forum and did not file the terms and conditions of the policy. It amounts negligence on the part of opposite parties. The opposite parties shall disclose on what ground they have limited the claim toRs.20,000/- as maximum permissible against the claim for Rs.48,000/-. The opposite party seems to have not given even reply to the notice issued by the complainant. Whenever a claim is disallowed either wholly or partly, the burden is on the opposite party to show the grounds or specific term permitting such disallowance. So we are of the opinion tht the complainant is entitled to the balance amount of Rs.28,000/- and costs of Rs.1,000/-. Interest may be allowed from the date of the Order.
POINT No.3:-
8. In the result, the complaint is allowed in part and the opposite parties are directed to pay Rs.28,000/- (Twenty eight thousand rupees only) to the complainant towards balance of hospital charges with interest @ 9% per annum from the date of order to till realization and to pay costs of Rs.1,000/- (One thousand rupees only) to the complainant within one month from the date of this order. The complaint for the rest of the reliefs is dismissed.
Typewritten by Stenographer K.Sivaram Prasad, corrected by me and pronounced by us in the open Forum, this the 6th day of February, 2014.
PRESIDENT MEMBER MEMBER
APPENDIX OF EVIDENCE
WITNESSES EXAMINED
For the complainant: For the opposite parties:-
P.W.1 A.Venkateswara Rao None.
Complainant
(by affidavit)
DOCUMENTS MARKED
On behalf of the Complainant:
Ex.A.1 . . Photocopy of Family Health Optima Insurance Policy – Schedule.
Ex.A.2 15.04.2013 Photocopy of Claim form for medical insurance.
Ex.A.3 05.04.2013 Photocopies of bunch of reports.
Ex.A.4 06.04.2013 Bunch of receipts and bills.
Ex.A.5 . . four prescription slips.
Ex.A.6 . . District summary issued by Centre for sight.
Ex.A.7 09.05.2013 Photocopy of letter from the opposite party to the complainant.
Ex.A.8 23.05.2013 Photocopy of letter from the complainant to the 2nd
opposite party.
Ex.A.9 11.06.2013 Photocopy of cheque for Rs.22,211/-.
Ex.A.10 28.06.2013 Photocopy of letter from the complainant to the 2nd opposite
party.
Ex.A.11 18.07.2013 Office copy of legal notice.
Ex.A.12 . . Postal acknowledgement.
Ex.A.13 . . Postal acknowledgement.
For the opposite parties:-
None.
PRESIDENT
