This C.C. is coming on before us for hearing in the presence of      Sri. Khaja Srinivasa Rao, Advocate for complainant; and of                         Sri. K. Ravindranath, Advocate for opposite parties No.1; and of              Sri. G. Sita Rama Rao, Advocate for opposite party No.3; notice of opposite party No.2 served called absent; upon perusing the material papers on record; upon hearing and having stood over for consideration, this Forum passed the following:-

O  R  D  E  R

(Per Sri R. Kiran Kumar, Member)

          This complaint is filed u/s.12-A of Consumer Protection Act, 1986. 

2.        The averments made in the complaint are that the complainant is resident of Khammam and she had savings account with opposite party No.1 Bank and opposite party No.2 had tie up with opposite party No.1 and opposite party No.3 used to cover the risk.  The complainant submitted that with said scenario the opposite party No.1 introduced a scheme of health insurance for the benefit of their account holders and accordingly opposite party No.1 developing a business.  The complainant further submitted that the opposite party No.1 used to deduct the amount from the account of its account holders and they remitting the same to the opposite party No.2 & 3, towards premium of health insurance.  The complainant submitted that she had attracted the scheme introduced by the opposite party No.1 and had purchased the health insurance policy bearing No.5054002815P103075013 valid from 09-06-2015 to 08-06-2016 and opposite party No.2 allotted a number for communication vide its number 133084.  The complainant submitted that she suffered with health problem and consulted doctors at Khammam and they proposed surgery of left chronic OTITIS + CENTRAL PERONATION and accordingly the complainant informed the same to the opposite party No.2, satisfied for the said proposed surgery the opposite party No.2 issued approved letter on 04-06-2015 and the said letter valid for one week. The complainant also submitted that as the policy is going to expire, she renewed her policy maintained by the opposite parties No.1 to 3 and it is valid from 09-06-2015 to 08-06-2016.  The complainant further submitted that she had underwent surgery on 10-06-2015 at Apollo Hospital, Jublihills, Hyderabad, as hospital authorities advised the complainant to go for surgery immediately and keeping in view of opposite parties No.2 confirmation letter, informed the same on phone, sending fresh confirmation letter will take time and she will make a claim by way of reimbursement of amounts by submitting bills for the expenses incurred.  Accordingly the complainant undergone surgery at Apollo Hospitals, Jublihills, Hyderabad on 10-06-2015 and hospital authorities charged a sum of Rs.69,857-15 ps. towards surgery, pharmacy and room rent as expenditure and at request of complainant the said charges scaled down to Rs.55,000/- and complainant paid the amount.  Complainant further submitted that after receiving discharge summary report and bills from the Hospital authorities, complainant made a claim with opposite party no.2 for reimbursement on 18-09-2015 under the acknowledgement.  The opposite parties dodging the matter in settling the claim, the complainant made correspondence with opposite party No.2 through mail by issuing requisition on 19, 22, 28 and 30^th of September 2015.  The opposite party informed the complainant that her complaint was closed on 1^st October 2015.  Vexing with the attitude of opposite party No.2 the complainant got issued legal notice to opposite party No.2.  Finally, the opposite parties settled the claim for a sum of Rs.31,403/- and said amount credited to complainant account, that is with opposite party No.1 by sending a letter dt.01-12-2015 through mail to the husband of the complainant and in the said letter it is also informed that if aggrieved she may claim.  The complainant further submitted in the letter the opposite party shown the entitle amount as Rs.46,200/-, but the strenuously the amount of Rs.14,857/- which was given as less by hospital authorities has been deducted from the entitlement amount and presided the final amount as Rs.31,403/- and the same has been credited to the account of the complainant.  The complainant further submitted that the opposite parties No.2&3 erroneously arrived to said amount but in fact she is entitled for Rs.55,000/- she is paid to the hospital authorities besides the attendant charges and transportation charges.  The complainant further submitted that she is entitled for a sum of Rs.23,597/- and Rs.25,000/- towards transportation charges and attendant charges totally a sum of Rs.48,597/- and also claimed  Rs.10,000/- towards sufferance of mental  agony and damages.        

3.        On behalf of the complainant, the following documents were filed and marked as Exhibits A-1 to A-5.

Ex.A1:-Photocopy of Insurance policy vide its No.05040028215P103075013 policy valid from 09-06-2015 to 08-06-2016.

Ex.A2:-Office copy of legal notice, dt. 30-10-2015 addressed to the opposite party No.2 along with postal receipt and acknowledgment.

Ex.A3:-Photocopy of Bill dated 14-06-2015 for an amount of Rs.55,000/-.

Ex.A4:-Photocopy of Authorization letter to the Hospital for treatment and as a guarantee of payment addressed by the opposite party No.2, dt.04-06-2015.                                      

Ex.A5:-Photocopy of claim settlement letter dated 10-12-2015 addressed by the opposite party No.2 to the complainant.                          

4.        On receipt of the notice, the opposite party No. 1 appeared through their council and filed counter.  In their counter the opposite party No 1 denied the averments made by the complainant in the complaint against them.  The opposite party No.1 submitted that the complainant misrepresented the facts and filed complaint against them for wrongful gain and to defame the Bank in the eye of public and the acts of opposite party No.1 caused mental agony to the complainant are not correct.  The opposite party No.1 further submitted that the AB Arogy dhaan is an exclusive floater health insurance policy for account holders of Andhra Bank in association with United India Insurance Co. Ltd. and the policy holder will be indemnified towards hospitalization expenses (as in patient only) incurred due to illness / the accidental injury subject to the terms, conditions and exclusions of the policy and also submitted that as per entitlement and also as per the terms and conditions of the policy the claim of the complainant was settled and the complainant is not entitled the amount as per her choice.  If any amount is payable to the complainant it is to be recovered from the opposite parties No.2 & 3 and the complainant is not entitled for the amount of Rs.58,597/-, and prayed to dismiss the complaint.

5.      On receipt of notice, opposite party No.3 filed counter stating that the complaint is not maintainable either in law or on facts.  The opposite party No.3 submitted that the insurance is contract indemnity, it has to be viewed as a normal contract as per the Indian Contract Act and any violation of the contract by the parties to the contract of insurance, the contract become void and in such an event the insurance company would not be liable to answer the claim of the other party.  The opposite party No.3 also submitted that they have not rendered any deficiency of service by declaiming the claim of the complainant and the complainant is not entitled for any of the claim.  The opposite party No.3 further submitted that they received document from the Good Health TPA services Limited i.e. opposite party No.2, basing on the document they paid amount on two occasions to the complainant (1) claim No.133084 claim amount of Rs.69,856/- and settlement amount Rs.35,403/-, transaction No.15C9H35315A10967 and (2) claim No.133084.1 claimed amount of Rs.18,335/- and amount settled for Rs.18,335/-, dt. 28-06-2016 vide transaction No.166S60436L301S48.  After scrutinizing the above paid total amount of Rs.49,738/-.  The amount of Rs.25,000/- of transportation and attendant charges which are fall under non-medical expenditure and not payable as per the terms and conditions of the policy.  The opposite party No.3 further submitted that the complainant by suppressing the material facts in his complaint, amount of Rs.49,738/- not shown in the complaint, it comes under suppression of material facts and tried to misguide the Forum, hence the complaint is liable to be dismissed.  The opposite party No.3 further submitted that the company sent a representation letter repudiating the claim, and the claim was not covered under the policy of insurance and hence the claim is not payable.  The opposite party No.3 further submitted that the claim of the complainant is not according to the terms and conditions of the policy and the complaint has no cause of action to file this complaint, as such this complaint is not maintainable and prayed to dismiss the complaint. 

6.      The opposite party No.3 filed photocopy of terms and conditions of policy under Good Health TPA Services Limited, which is marked as Exhibit B-1.

7.      Opposite parties No.1 & 3 filed Written Arguments.

8.      Upon perusing the material available on record, now the point that arose for consideration is,

Whether the complainant is entitled for the claim?

Point:-

In this case the complainant is having savings account with opposite party No.1 Bank and opposite party No.2 had tie up with opposite party No.1 and opposite party No.3 used to cover the risk.  According to the complainant the opposite party No.1 introduced a scheme of health insurance for the benefit of their account holders, the complainant had attracted the scheme introduced by the opposite party No.1 and had purchased the health insurance policy bearing No.5054002815P103075013 valid from 09-06-2015 to 08-06-2016 and opposite party No.2 allotted a number for communication vide its number 133084.  The complainant suffered with health problem and consulted doctors at Khammam and they proposed surgery of left chronic OTITIS + CENTRAL PERONATION and accordingly the complainant informed the same to the opposite party No.2, satisfied for the said proposed surgery, the opposite party No.2 issued approved letter on 04-06-2015 and the said letter valid for one week.    As the policy is going to expire, the complainant renewed her policy maintained by the opposite parties No.1 to 3 and it is valid from 09-06-2015 to 08-06-2016.  The complainant underwent surgery on 10-06-2015 at Apollo Hospital, Jublihills, Hyderabad and hospital authorities charged a sum of Rs.69,857-15 ps. towards surgery, pharmacy and room rent as expenditure and at request of complainant the said charges scaled down to Rs.55,000/- and complainant paid the amount.  After receiving discharge summary report and bills from the Hospital authorities, complainant made a claim with opposite party no.2 for reimbursement on 18-09-2015.  According to the complainant, as the opposite parties dodging the matter in settling the claim, she made correspondence with opposite party No.2 through mail.  But the opposite party informed the complainant that her complaint was closed on 1^st October 2015.  Vexing with the attitude of opposite party No.2 the complainant issued legal notice to opposite party No.2 on that the opposite parties settled the claim for a sum of Rs.31,403/- and credited the amount to complainant’s account.  According to the complainant, the opposite parties No.2 & 3 erroneously arrived to said amount but in fact she is entitled for Rs.55,000/- as she paid the said amount to the hospital authorities besides the attendant charges and transportation charges.  According to the complainant she is incurred a sum of Rs.23,597/- and Rs.25,000/- towards transportation charges and attendant charges totally a sum of Rs.48,597/- and also claiming  Rs.10,000/- towards sufferance of mental  agony and damages.   As the opposite parties failed to pay the total expenditure incurred by her, for that she approached the Forum for redressal.

From the documents and material available on record we observed that, the opposite party No.3 received the documents from the Good Health TPA services Limited for the reimbursement claim of the complainant, basing on the documents the opposite party No.3 paid two occasions i.e (1) claim No.133084 claim amount of Rs.69,856/- and settlement amount Rs.35,403/-, transaction No.15C9H35315A10967 and (2) claim No.133084.1 claimed amount of Rs.18,335/- and amount settled for Rs.18,335/-, dt. 28-06-2016 vide transaction No.166S60436L301S48.  After scrutinizing the above paid total amount of Rs.49,738/-  as per the terms and conditions of the policy and repudiated the amount of Rs.25,000/- of transportation and attendant charges which fall under non-medical expenditure.  It is indisputable that the complainant underwent surgery on 10-06-2015 at Apollo Hospitals, Jublihills, Hyderabad and for which the complainant has paid as per the policy conditions.  The complainant failed to submit any documentary evidence, i.e. bills for attendant charges and transport charges, and also as per the terms and condition No.6.18 to 6.20 of the policy (Exhibit B-1) she is not entitled for transportation and attendant charges which fall under non-medical expenditure.  The opposite parties after scrutinizing the claim, paid total amount of Rs.49,738/- to the complainant as per the terms and conditions of the policy.  In view of the above circumstances we are of the opinion that the opposite parties settled the claim as per the terms and conditions of the policy, as such this point is answered against the complainant.

9.      In the result, the complainant is dismissed.  No costs.

          Typed to dictation, corrected and pronounced by us, in the open forum on this the 20^th day of July, 2017.       

Member                   Member               President

                                                          District Consumer Forum,

Khammam.

APPENDIX OF EVIDENCE

WITNESSES EXAMINED:-

For Complainant:-                                                 For Opposite party:-   

       -None-                                                                       -None-

DOCUMENTS MARKED:-

For Complainant:-                                                           For Opposite party:-   

Member                   Member               President

                                                          District Consumer Forum,

Khammam.