3

by the complainant as account holder under policy No. 050400/48/07/41/00000075

as renewed policy. The earlier policy of 2007 was renewed with validity period from

6-3-2008 to 5-3-2009 covering Rs. 3,00,000/-. It was not correct that Rs. 1,81,600/-

was only paid instead of Rs. 2,37,616/- towards hospitalization bill. It was not

correct that the respondents failed to pay the amount causing mental agony to the

complainant. The complainant had the policy for sum assured Rs. 2,00,000/- since

6-3-2007 and it was enhanced from Rs. 2,00,000/- to Rs. 3,00,000/- for the period

commenced from 6-3-2008 to 5-3-2009. Under the terms and conditions it would

not cover to pre-existing conditions and ailments. The discharge summary issued by

Apollo Hospitals, Hyderabad for the treatment period of the complainant from

3-9-2008 to 5-9-2008 disclosed “pain left hand on minimal exertion since one year

and CAG showed Triple vessel disease”. He was diagnosed in the category of CAD -

UAP – DM. He was suffering from pain left hand on minimal exertion since one year.

The present ailment was in existence prior to inception of the policy and the

complainant’s treatment charges were limited to earlier policy sum assured of

Rs. 2,00,000/- and remaining balance was payable only to new diseases, but not

earlier existing ailments. The R3 received the pre authorization request note from

Apollo Hospitals for treatment of the complainant and approved the same for

Rs. 18,000/- and informed to the hospital vide PA No. 58699, dt. 24-8-2008. On

8-9-2008 the R3 received claim documents from the hospital for reimbursement

charges during the hospitalization period from 25-8-2008 to 26-8-2008 and

requested to pay Rs. 17,507/-. The respondent settled the claim for Rs. 15,756/-

and sent to the hospital vide cheque No. 311169, dt. 18-9-2008. The R3 received

another pre authorization request note from Apollo Hospital for the treatment of the

complainant and approved the same for Rs. 1,82,000/- and informed the hospital

vide P.A. No. 58973, dt. 5-9-2008. The R3 received claim documents on 15-8-2008

for reimbursement from the hospital during the hospitalization from 3-9-2008 to

5-9-2008 to pay Rs. 1,82,000/- out of a total treatment cost of Rs. 2,37,617/-. The

4

respondent settled the claim for Rs. 1,63,440/- and remitted to the hospital vide

cheque No. 311251, dt. 19-9-2008. Thus the respondent honoured the claim to an

extent of Rs. 1,79,196/- and the surplus amount of Rs. 20,804/- only to be entitled

by the complainant under the policy for the sum insured Rs. 2,00,000/-. The

complainant enhanced insured amount from Rs. 2,00,000/- t o Rs. 3,00,000/-.

Whereas the present hospitalization period was for the treatment of existing ailment

and hence, the reimbursement amount was restricted to the earlier policy sum

insured amount of Rs. 2,00,000/-. Thus the respondent repudiated the claim in

terms of the conditions of the policy. The complainant was not entitled and the

respondent was not liable to pay Rs. 56,017/- as claimed by the complainant. The

respondent sent a reply on 4-11-2008 to the notice sent by the complainant. Thus

the complaint may be dismissed with costs.

6. The R3 was called absent and set exparte on 2-2-2009.

7. On the basis of the above pleadings the following points are settled for

determination.

i. Whether there is any negligence and deficiency of service on the

part of the respondents?

ii. Whether the complainant is entitled to the relief as prayed for?

iii. To what relief?

8. On behalf of the complainant Ex. A1 to A6 were marked and on behalf of

the respondents Ex. B1 to B5 were marked. The complainant filed the written

arguments.

9. Point No. 1 & 2 The complainant was an account holder of the R1 bank.

The R1 bank introduced a health insurance plan called A.B Arogyadaan scheme to its

account holders interlinked with R2 and R3. The duration of the policy was one year

renewed every year. The complainant took the policy in 2003 and renewed in 2008

for the period from 6-3-2008 to 5-3-2009 for a sum assured Rs. 3,00,000/- under the

5

policy No. 050400/48/07/41/00000075. Ex. A1 was the Xerox copy of health

insurance card issued by the respondents. There was no dispute about the policy

taken by the complainant. On 3-9-2008 the complainant got admitted in to Apollo

Hospitals, Hyderabad for heart problem and was discharged from the hospital on

5-9-2008. The Xerox copy of the discharge summary filed by the complainant was

Ex. A2 and same copy was filed by the respondents under Ex. B2. Under Ex. A2 as

well as Ex. B2 the Chief complaint of the complainant was “pain left hand on minimal

exertion since one year” CAG showed Triple vessel Disease. Admitted for further

management”. The complainant mentioned in the complaint that R2 and R3 remitted

Rs. 30,000/- towards angiogram to the hospital. The complainant filed Ex. A3 Xerox

copy of bill issued by the Apollo Hospitals, Hyderabad for Rs. 2,37,616-86Ps and the

hospital authorities received Rs. 1,81,600/- from R3. The complainant paid the

remaining balance amount of Rs. 56,017/- to the hospital and got discharged on

5-9-2008. Subsequently the complainant got issued a notice to the respondents to

pay Rs. 56,017/- towards hospitalization charges because the complainant under the

medical insurance policy was entitled for Rs. 3,00,000/- towards hospitalization

charges. The Xerox copy of the notice was Ex. A4. Ex. A5 was the postal receipts.

Ex. A6 was postal acknowledgments.

10. The Respondents filed Ex. B1 a copy of member benefit plan information

sheet that the pre-existing conditions under the policy would not be covered. The

complainant mentioned that he took the policy since 2003 for one year duration and

was the renewed in 2008 for sum assured Rs. 3,00,000/- towards medical expenses.

Ex. B3 copy of letter from R3 to R2 dt. 19-11-2008. Ex. B4 was the Xerox copy reply

notice to Ex. A4 from R2 to the complainant. Therefore, the previous policy bearing

No. 050400480064100000116 was mentioned for Rs. 2,00,000/- as sum assured.

The total sum assured was Rs. 20 crores for 100 proposals from various branches

under the scheme. Under the salient futures of the A.B Arogyadaan group medi

6

claim insurance policy it was clear that “in case of enhancement of sum insured

during subsequent renewals the additional sum assured will be treated as fresh

policy and No. renewal benefits will accrue for additional sum insured”. In view of

the said condition the complainant was not entitled for his claim of Rs. 56,017/-.

The original policy was for Rs. 2,00,000/- and the respondents reimbursed and paid

Rs. 1,79,196/- i.e. Rs. 15,756/- on 18-9-2008 for hospitalization charges from

25-8-2008 to 26-8-2008 and Rs. 1,63,440/- on 19-9-2008 totaling Rs. 1,79,196/-.

Thus the surplus amount entitled by the complainant under the policy was

Rs. 20,804/-. The complainant suppressed the earlier settlement of the claim for

Rs. 15,756/- for h is treatment from 25-8-2008 to 26-8-2008 though his claim was

Rs. 17,507/-. The R2 settled the said claim for Rs. 15,756/- and paid to the hospital

by way of cheque dt. 18-9-2008. Subsequently hospital charges were reimbursed for

t h e p r e s e n t treatment f r o m 3 -9-2008 to 5-9-2008 under the claim of

Rs. 1,81,600/- out of a total treatment cost of Rs. 2,37,617/-. But the R2 settled the

claim to an extent of Rs. 1,63,440/- and paid the amount to the hospital by way of

cheque dt. 19-9-2008. So the total amount under the two claims was Rs. 1,79,196/-

(Rs. 15,756/- + Rs. 1,63,440/-). Thus there was no deficiency of service on the part

of the respondents. The complainant was not entitled to Rs. 56,017/- as claimed.

He was entitled only Rs. 20,804/- as admitted by the R2 and in its counter.

11. Point No. 3 In the result, the complaint is allowed for Rs. 20,804/-

(Rupees Twenty Thousand eight hundred and four only), without interest and costs

and compensation, payable by R2 only within 45 days from the date of receipt of the

order. The case against R1 & R3 is dismissed without costs.

Dictated to the Stenographer, transcribed by him, corrected and pronounced

by us in the open forum, this the 13

MEMBER MEMBER PRESIDENT

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APPENDIX OF EVIDENCE

Witnesses examined.

For Complainant : NIL For Respondent : NIL

Exhibits marked for Complainant : -

Ex. A1 X/c of the A.B Arogyadaan Health Paln Ltd., card.

Ex. A2 X/c of discharge summary issued by Apollo Hospitals, Hyderabad.

Ex. A3 X/c of bill issued by by Apollo Hospitals, Hyderabad, dt. 8-9-2008.

Ex. A4 X/c of legal notice from complainant’s advocate to respondents,

dt. 22-9-2008.

Ex. A5 Three postal receipt Nos. 3147 to 3149.

Ex. A6 Three postal acknowledgements.

Exhibits marked for Respondents: -

Ex. B1 X/c of Member benefit plan information sheet, dt. 15-9-2008.

Ex. B2 Discharge summary issued by Apollo Hospitals, Hyderabad.

Ex. B3 X/c of letter from R3 to R2, dt. 19-11-2008.

Ex. B4 X/c of letter from R2 to complainant’s advocate, dt. 4-11-2008.

Ex. B5 Group mediclaim – tailor made policy issued by R2 in favour of R1.

MEMBER MEMBER PRESIDENT

Copy to :-

1) Sri P. Subramanyam, Advocate.

2) Sri G. Sreenivasulu Naidu, Advocate.

3) Sri K. Venu Gopal, Kadapa.

4) Family Health Plan Limited, Rep. by its Manager,

Aditya JR towers, #8-2-120/86/9/A&B, 3

Road No. 2, Banjarahills, Hyderabad.

1) Copy was made ready on :

2) Copy was dispatched on :

3) Copy of delivered to parties :

B.V.P. - - -