DISTRICT FORUM :: KADAPA

PRESENT SRI P.V. NAGESWARA RAO, M.A., LL.M., PRESIDENT

                                                          SRI S. ABDUL KHADER BASHA, B.Sc., MEMBER

Tuesday, 25th November 2008

CONSUMER COMPLAINT No.  81 / 2008

Cheemalamarri Sreenivasa Rao, S/o Venkateswarlu,

39 years, Hindu, working as Clerk Cashier,

Andhra Pragathi Grameena Bank, Porumamilla,

Kadapa district.                                                                          ….. Complainant.

Vs.

1)  The Oriental Insurance Co. ltd., Nellore, Rep. by its

     Branch Manager,  

2)  The Oriental Insurance Co. Ltd., Kadapa Rep. by its

     Branch Manager.                                                                 ….. Respondents. 

This complaint coming on this day for final hearing on 24-11-2008 in the presence of Sri M. Suresh Kumar, Advocate for complainant and Sri G. Ramachandra Reddy, Advocate for respondents and upon perusing the material papers on record, the Forum made the following:-
O R D E R

(Per Sri P.V. Nageswara Rao, President),

1.                Complaint filed under section 12 of the Consumer Protection Act 1986.

2.                The brief facts of the complaint is as follows:-  The complainant was a Clerk cum Cashier in Andhra Pragathi Grameena Bank, Porumamilla Branch, Kadapa District.  He had one personal accident policy ‘Nagrik Suraksha policy’ bearing No. 248/2006 commenced for a period from 27-12-2005 to 26-12-2009 with a premium of Rs. 1,821/- with assured sum of Rs. 5,00,000/- i.e. Rs. 4,00,000/- towards personal accident and Rs. 1,00,000/- towards hospitalization. 

3.                The complainant met with an accident on 15-7-2006 and sustained left fore arm both bones fracture non-union.   He underwent first surgery for both bones and plates and screws were fixed.  It was at Jaya Bharath Hospital, Nellore.  He presented bills to an extent of Rs. 28,000/- to the R1 and claim was settled for that amount.  The policy was taken from R1. 

4.                The complainant was advised to undergo 2nd surgery for removal of plates and screws.  It was conducted on 24-12-2007.  After taking X-rays on 19-1-2008 certain complications were found.  The hand was bent like that of fracture.  The complainant approached Apollo Hospitals on 21-2-2008 for expert opinion, who expressed that bones were not set properly and advised for re-surgery by plating and bone grafting.  The complainant underwent 3rd surgery and the same was brought to the notice of the respondents that the surgery was on 8-5-2008.  Later the complainant made a claim to R1 for Rs. 86,575-66Ps.  But it was repudiated on the ground that it was out side the scope of the policy.  The 3rd surgery was a continuation process of the 1st and 2nd surgery under medical advice.  As the policy was covered up to Rs. 1,00,000/- and as the R1 paid Rs. 28,000/-, the complainant was entitled to Rs. 72,000/- for 2nd and 3rd surgeries along with compensation of Rs. 12,000/- for deficiency of services.  The non-union of both bones was on account of accident and due to it the complainant was hospitalized and hence, the present complaint was filed for Rs. 84,000/- with interest @ 18% p.a. from the date of complaint till payment and Rs. 2,000/- towards costs. 

5.                The respondents filed a counter that the complainant claimed medical expenses soon after he was discharged from the hospital.  There was no notice that further surgery was required.  He did not inform further treatment in two years after 1st claim for 2nd operation.  After 1st operation he was fit to attend to normal duties.  So the earlier case was ceased to operate once he became fit to attend to normal duties.  As per section – 2 of policy conditions, reimbursement of hospitalization expenses following bodily, directly from the accident were payable and consequential loss of any kind was excluded from the scope of cover.  The respondent was not liable for any compensation.  The complainant was not entitled to claim medical expenses for 2nd surgery as the 1st operation was reimbursed in 2006.  The respondent had fulfilled the conditions of the policy.  The non-union of both bones was out side the scope of the policy and hence, the claim was repudiated.  There was no deficiency of service on the part of the respondents. 

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

i.                   Whether there is any 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?

7.                On behalf of the complainant Ex. A1 to A12 were marked and on behalf of the respondents Ex. B1 was marked.   

8.                Point No. 1 & 2  The personal accident policy namely ‘Nagrik Suraksha Policy’ (personal accident with hospitalization expenses insurance policy) issued by R1 under policy No. 248/2006 with premium of Rs. 1,821/- for a period from               27-12-2005 to 26-12-2009 for the sum assured Rs. 4,00,000/- towards personal accident to the complainant and Rs. 1,00,000/- towards hospitalization totaling  Rs. 5,00,000/- was not a dispute.  The complainant filed Ex. A1 Xerox copy of the policy.  The respondent filed Ex. B1 a copy of terms and conditions of the policy.  There was no dispute that the complainant met with an accident on 15-7-2006 and underwent a surgery for multiple fracture of both bones and fixing of plates, screws to both bones of left forearm and R1 settled the claim for Rs. 28,000/-.  The sum assured under hospitalization under the policy was Rs. 1,00,000/- and out of it the respondents settled Rs. 28,000/- to the complainant.  The complainant claimed Rs. 72,000/- as balance amount towards hospitalization out of Rs. 1,00,000/- and Rs. 12,000/- towards deficiency of service and Rs. 2,000/- towards costs.  Certain complications arose after the 2nd surgery was conducted on 24-12-2007, for removal of plates and screws.  So, subsequent to 2nd surgery, X-rays were taken on 19-1-2008 and found certain complications.  Thus the complainant approached Apollo Hospital, Chennai for expert opinion where he was forced to undergo a 3rd surgery and hence, it was conducted on 8-5-2008.  To that effect the complainant addressed a letter to R1.  The Xerox copy of the letter was Ex. A2 sent by registered post to R1 from Porumamilla.  The Apollo Hospitals, Chennai issued a letter that the complainant was required further treatment of left forearm both bones fracture non-union.  The Xerox copy of the letter was Ex. A3 dt. 21-2-2008.  The complainant was admitted in Apollo Hospitals, Chennai on 7-5-2008 and discharged on 10-5-2008.  He produced Ex. A5 Xerox copy of inpatient bills for Rs. 86,575-66Ps.  Ex. A6 was Xerox copy of discharge summary after first surgery issued by Jaya Bharath Hospital, Nellore dt. 23-7-2006. Ex. A7 was another discharge summary issued by Jaya Bharath Hospital, Nellore after conducting 2nd surgery for removal of plates and screws.  He was discharged from Jaya Bharath Hospital, Nellore on 27-12-2007.  Ex. A8 was Xerox copy of discharge summary issued by Apollo Hospitals, Chennai, after conducting the 3rd surgery to the complainant.  Ex. A9, A10, A11 and A12 were X-rays taken by Apollo Hospitals, Chennai. 

9.                The respondents contended that the 3rd surgery conducted by Apollo Hospitals, Chennai was not in continuation of the earlier two surgeries to multiple fractures of both bones to left forearm, because the 3rd surgery was conducted two years after 1st surgery.  The 1st surgery was conducted on 16-7-2006 and the 3rd surgery was conducted on 8-5-2008.  In between first and 3rd surgery the complainant was in fit condition and was working and attending to his regular duties.  The 3rd surgery at Apollo Hospital, Chennai was not a surgery to another bone problem.  It was conducted to the same left fore arm both bones fracture non-union.  The 2nd surgery at Jaya Bharath Hospital, Nellore was only for removal of plates and screws fixed at the time of 1st surgery.  After removal of the plates and screws on 24-12-2007 certain complications were noticed and hence, the complainant was advised to undergo better treatment and thus he was forced to undergo 3rd surgery on 8-5-2008 at Apollo Hospital, Chennai.  Therefore, the 3rd surgery was in continuation of the 1st surgery.  The respondents repudiated the claim and issued a letter dt. 01-7-2008.  The Xerox copy of the repudiation letter was Ex. A4.  Therefore, the repudiation was not legal and hence, there is deficiency of service on the part of the respondents.  Hence, the points are answered accordingly. 

10.              Point No. 3 In the result, the complaint is allowed.  Directing the respondents 1 & 2 jointly and severally to pay Rs. 72,000/- (Rupees Seventy Two Thousand Only) towards compensation and Rs. 5,000/- (Rupees Five thousand Only) towards deficiency of service and Rs. 1,000/- (Rupees One thousand only) towards costs totaling Rs. 78,000/- (Rupees Seventy Eight Thousand Only) within 60 days from the date of receipt of this order.  

Dictated to the Stenographer, transcribed by him, corrected and pronounced by us in the open forum, this the 25th November 2008
 
 
 
MEMBER                                                                                            PRESIDENT
APPENDIX OF EVIDENCE

Witnesses examined.

For Complainant    :       NIL                            For Respondent :     NIL

Exhibits marked for Complainant  : -  

Ex. A1         X/c of insurance policy issued in favour of the complainant.

Ex. A2         X/c of letter from complainant to R1, dt. 01-5-2008.

Ex. A3         X/c of letter from Apollo Hospitals, Chennai to the complainant,

dt. 21-2-2008

Ex. A4         X/c of repudiation letter from R1 to the complainant, dt. 1-7-2008.

Ex. A5         X/c of inpatient bills issued by Apollo Hospitals, Chennai.

Ex. A6         X/c of discharge summary issued by Jaya Bharath Hospital, Nellore

dt. 23-7-2006.

Ex. A7         X/c discharge summary issued Jaya Bharath Hospital, Nellore,

dt. 27-12-007

Ex. A8         X/c of discharge summary issued by Apollo Hospitals, Chennai. 

Ex. A9

Ex. A10       X-rays issued by the Apollo Hospitals, Chennai.

Ex. A11

Ex. A12      

Exhibits marked for Respodnents : -         

Ex. B1        X/c of “Nagrik Suraksha policy’ terms and conditions.

MEMBER                                                                                          PRESIDENT
Copy to :-

1) Sri M. Suresh Kumar, Advocate. 

2) Sri G. Ramachandra Reddy, Advocate. 

         1) Copy was made ready on     :

2) Copy was dispatched on      :

3) Copy of delivered to parties :
 
B.V.P.                                               - - -