This C.C. coming before us for hearing in the presence of Sri Mamidi Hanumantha Rao, Advocate for complainant and of Sri Kothapalli Rama Rao, Advocate for opposite parties No.1 & 2; 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 Smt.V.Vijaya Rekha, Member)

This complaint is filed under section 12(1) of the Consumer Protection Act, 1986. 

2.       The brief facts as stated in the complaint are that the complainant has been practicing as an advocate, obtained Medi Claim Group Insurance policy vide policy ID.No.ICUI1400083981 for a period of one year under advocate group insurance policy in favour of his family members (5 Members) including his parents for Rs.1,00,000/- to each person.  During the policy was in force i.e. on 24-09-2011 the father of complainant had sustained fracture injuries to his left hip joint due to fall on the road and joined as in-patient in Prasad Ortho & Spine Trauma Care Centre on 30-09-2011.  The doctor inserted steel rods and implants by conducting surgery on 01-10-2011.  While taking the treatment as in-patient i.e. on 05-10-2011 the father of complainant had suffered cardiac problem, immediately he was shifted to Spandana Cardiac Hospital, Khammam.  Wherein, he was treated as in-patient on ventilator till 10-10-2011, after discharging from Spandana Hospital he was rejoined in Prasad Ortho Hospital for continuation of treatment for fracture injuries and from there, he was discharged on 13-10-2011.  The complainant also stated that he intimated the incident and joining of hospital to the opposite parties, so, it is the duty of the insurer to pay insurance amounts under cashless policy according to the norms but the opposite parties did not do so, therefore, alleges the deficiency of service on the part of opposite parties.  The complainant further submitted that upon directions of authorities of opposite parties, submitted required documents on 31-10-2011.  The opposite party No.1 registered the claims vide its Nos.31964 and 32084 as the father of complainant had obtained treatment from two different hospitals.  The complainant further alleges that the opposite parties made unnecessary queries in written only to avoid payment of insurance amounts.  Therefore, the complainant got issued reply by furnishing hospital bills and receipts for Rs.54,300/- and Rs.12,847/- towards pharmacy bills regarding the treatment at Prasad Ortho, Spine and Trauma Care Centre, Khammam along with the bills and receipts for Rs.78,216/- and Rs.24,631/- towards pharmacy bills for treatment at Spandana Hospital Khammam, even though, the opposite parties did not pay the amount and further demanded the detailed bills and case history.  Upon which, the complainant had sent the detailed bills and case history to the opposite parties on 03-01-2012.  After making many rounds, they have issued a cheque for Rs.56,989/- on 01-08-2012 towards medi claim expenses of Spandana Hospitals, Khammam.  The complainant also submitted that he entitled to get Rs.43,000/- along with interest from the opposite parties towards mental agony, sufferance and the other expenses.   The complainant issued legal notice dt. 10-10-2012 as there was no response in payment of insurance amounts and finally approached this Forum by praying to direct the opposite parties to pay Rs.43,000/- towards medical reimbursement together with interest @ 12% per annum and Rs.1,00,000/- towards damages and costs. 

3.       In support of his case, the complainant filed exhibits A-1 to A-20.

4.       After service of notice, the opposite parties appeared and filed counter by submitting that the insured has to inform the incident immediately to the TPA/insurer to investigate the cause of accident and other material facts for payment of benefits under Group Medi Claim Policy.  The insured intimated the incident after one week of accident, the accident took place on 24-09-2011 but the intimation was given after one week i.e. on 30-09-2011.  The patient joined in the hospital and underwent surgery without any prior approval of insurer.  The treatment given by the hospital has no tie-up with TPA/insurer, therefore, the insured ought to have obtained prior approval from the insurer prior to the joining of hospital, even in respect of Heart treatment neither the insured nor the person of Hospital informed the opposite parties, so, the insurer was deprived to examine the patient prior to taking of treatment.  The hospitals, those having tie-up facility are allowable to cashless facility.  In the absence of tie-up facility, the insured has to give immediate notice to the TPAs to examine the patient, otherwise, insured has to bare the expenses and seek reimbursement under terms and conditions of policy.  The documents submitted belatedly on 03-01-2012, which is against the policy conditions.  Therefore, prayed to dismiss the complaint as there was no deficiency of service on the part of opposite parties.    

          Along with a petition vide IA.No.21/2014 the counsel for opposite parties filed exhibits B-1 to B-3.   

5.       Both the parties filed Written Arguments by reiterating the same averments as mentioned in the complaint and counter.

6.       In view of above circumstances, now the point that arose for consideration is,

          Whether the complainant is entitled to the relief

                    as prayed for?

Point:-                  

According to the afore stated facts, it is clear that the opposite party No.1 / insurer was settled the claim in respect of treatment at Spandana Cardiac Hospital, Khammam and released cheque bearing No.625426, dt. 01-08-2012 for Rs.56,989/- but in respect of another claim for taking treatment at Prasad Ortho & Spine Trauma Care Centre, Khammam from 30-09-2011 till 13-10-2011 was not settled by the reason of non-intimation of accident and treatment prior to hospitalization and delay in sending of required documents to the insurer.  In their counter the opposite parties averred that the patient was joined in the hospital and underwent surgery without any prior approval of the insurance company.  The treatment given by the hospitals have no tie-up facility with the insurer, in the absence of tie-up facility the insured has to give immediate notice prior to the hospitalization.  Therefore, there is no deficiency of service on their part in settlement of claim under cashless policy.  After having perused the material filed by both the parties it is a fact that the father of the complainant had sustained fracture injuries due to fall on the ground and admitted as in-patient in Prasad Ortho & Spine Trauma Care Centre, Khammam on 30-09-2011 and taken the treatment as in-patient till 13-10-2011, during the treatment for fracture injuries he referred to Spandana Cardiac Hospital for obtaining treatment for sudden heart problem, evidence under exhibits A-4 to A-17, exhibit A-5, A-6 and exhibit A-8 are relating to discharge summaries, speaks the same.  Moreover, the investigation report, placed by the opposite parties also stated that the patient was treated by Dr. Prasad Babu at his hospital from 30-09-2011 his fracture injuries, evidenced under Exhibit B-3.  And as per the averments of counter, it is clear that the opposite parties have received the information regarding the accident as on the date of hospitalization.  Therefore, the plea taken by the opposite parties regarding non-intimation prior to the hospitalization is not acceptable,  therefore, they did not escape from their liability by raising mere technical grounds, so, it is the bounden duty of the opposite party No.1 to settle the claim of  complainant in respect of Prasad Ortho & Spine Trauma Care Centre also according to the terms and conditions of the policy schedule as mentioned under clause 1.2.1(b) and as such the point is answered accordingly in favour of the complainant by holding that the opposite party No.1 is also liable to settle the claim in respect of treatment taken by the insured at Prasad Hospital.     

7.       In the result, the complaint is allowed in part, directing the opposite party No.1 to pay the insurance amounts to complainant under Medi Claim Group Insurance policy vide policy ID.No.ICUI1400083981 together with interest @ 9% per annum i.e. from 01-08-2012 till realization for taking treatment at Prasad Ortho & Spine Trauma Care Centre by settling the claim under terms and conditions of the policy within one month from the date of receipt of this order.  Further directed to pay Rs.1,000/- towards costs.  The complaint against opposite party No.2 is dismissed.

           Typed to my dictation, corrected by me and pronounced by us, in this Forum on this the 31^st day of August, 2016.                                                          

                         FAC President              Member

District Consumer Forum, Khammam

APPENDIX OF EVIDENCE

WITNESSES EXAMINED:-

For Complainant:-                                                     For Opposite party:-   

       -None-                                                                           -None-

DOCUMENTS MARKED:-

For Complainant:-                                                     For Opposite party:-   

FAC President               Member

District Consumer Forum, Khammam