Andhra Pradesh

Chittoor-II at triputi

CC/48/2015

A.Yerram Reddy, S/o. A.Subba Reddy - Complainant(s)

Versus

The Chief Manager, National Insurance Company Ltd., - Opp.Party(s)

K.V.Bhaskar

18 Nov 2016

ORDER

    Filing Date: 13.10.2015

                                                                                                   Order Date:  18.11.2016

 

 

 

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-II,

CHITTOOR AT TIRUPATI

 

 

      PRESENT: Sri.M.Ramakrishnaiah, President ,

        Smt. T.Anitha, Member

 

 

 

FRIDAY THE EIGHTEENTH DAY OF NOVEMBER, TWO THOUSAND AND SIXTEEN

 

 

 

C.C.No.48/2015

 

 

Between

 

 

A. Yerram Reddy, S/o. A. Subba Reddy,

19-4-8/P-405, Sarathi Shelters,

S.T.V. Nagar, AIR Byepass Road,

Tirupati, chittoor District.                                                      … Complainant

 

 

 

And

 

 

1. The Chief Manager,

National Insurance Company Ltd.,

Head & Registered office,

No.3, Middleton Street,

Middleton Row, kolkata – 700071.

 

2. The Chief  Manager,

Family Health Plan Ltd. (TPA),

Srinilaya-Cyber Spazio,

Suite # 101, 102, 109  & 110,

Ground Floor, Road No.2,

BanjaraHills, Hyderabad-500 034.                                   …  Opposite parties.

 

 

 

 

            This complaint coming on before us for final hearing on 10.11.16 and upon perusing the complaint, written version and other relevant material papers on record and on hearing Sri.K.V.Bhaskar, counsel for complainant,and Sri. D.Damodar Reddy, counsel for opposite party, and having stood over till this day for consideration, this Forum makes the following:-

ORDER

DELIVERYED BY SRI. M.RAMAKRISHNAIAH, PRESIDENT

ON BEHALF OF THE BENCH

           

            This complaint is filed under Sections – 12 and 14 of Consumer Protection .Act 1986, by the complainant against the opposite parties 1 and 2 for the following reliefs  1) to direct the opposite parties to pay  Rs.1,13,700/- to the complainant for his treatment along with Rs.25,000/- towards other expenses and also to pay Rs.50,000/- towards damages for causing mental agony to the complainant 2) to direct the opposite parties to pay Rs.3,000/-  towards costs of the complaint  and pass such other or further reliefs as the Forum, may deem fit and proper in the circumstances of the case.    

            2.  The brief averments of the complaint are:-  that the complainant is an employee in Lanco Industries Ltd., now called as Srikalhasti Pipes Ltd.,. The complainant has taken a policy with UHID No. NIC00008494791 under E-ID No.69 bearing policy No. 100100/46/14/8500000025 for the plan period from 01.04.2014 to 31.03.2015 the said policy was given for all the employees under group policy by opposite party no.1. Opposite party no.2 who is the third party administrator sent a identity card with certain terms and conditions along with a small booklet mentioning the list of Network Hospitals (South) the premiums for the said policy were deducted from his salary at his working place. Except the ID card and the list of Network Hospitals no other document was furnished to the complainant either by opposite party No.1 or opposite party No.2. For cashless benefit, treatment has to be taken in network hospitals only preauthorization is compulsory for cashless, for planned hospitalization , to be informed at least 7 days before. For emergency cases  to be informed within 24 hours of admission, for reimburse claims, TPA has to be informed within 7 days of hospitalization and prior to discharge. All terms and conditions of the insurance policy are applicable.

            3.  That the complainant suspected heart problem for him and thought of taking treatment in a network hospital and he approached IRUDAYAM Hospital Private Ltd.  Nagarcoil, Tamilnadu. After consultation with the Doctor he was diagnosed , in the Cardio Vascular Cartogram Test that he is suffering from Triple Vessel Coronary Artery Disease and advised him to admit in the hospital. Accordingly the complainant joined in the hospital as advised on 16.01.2015, after undergoing treatment he was discharged on 26.01.2015. For the treatment he spent Rs.1,13,700/- as per receipt No.1408 dated 26.01.2015. Apart from the said amount he had spent Rs.25,000/- for traveling and his assistants cost. After the treatment, complainant intimated the same to opposite party No.2, in turn opposite party No.2 asked the complainant to send the entire case sheet and relevant documents along with the claim. Accordingly complainant sent the claim along with entire documents. The complainant received a reply from opposite party No.1 dated 23.02.2015 stating that the treatment is not covered under the purview of standard Group Mediclaim Policy and the claim is closed treating it as “ NO CLAIM” and claim is REPUDIATED thus opposite parties caused mental agony to the complainant and committed deficiency in service. Hence the complaint.

          4.  Opposite party No.1 filed his written version and the same is adopted by opposite party No.2. In the written version opposite parties 1 and 2 have admitted that the complainant is an employee in Lanco Industries Ltd., which is now calling Srikalhasthi Pipes Ltd., that he has taken policy with UHID No.NIC00008494791 under E-ID No.69 bearing policy No. 100100/46/14/8500000025 for the plan period from 01.04.2014 to 31.03.2015. The said policy is a group policy given by opposite party No.1. After obtaining the said policy from opposite party No.1, opposite party No.2 sent ID card with certain terms and conditions and they also sent a small booklet mentioning a list of Network Hospitals (South). Opposite parties further admitted the (contents (Para-4) of complaint )that except the ID card and the list of network hospitals no other documents were furnished to the complainant. The ID card is only for identity purpose for cashless benefit, if treatment is taken in the Network Hospitals only etc conditions. And denied other allegations in the complaint.

            5.  The opposite parties further contended that the complainant has not submitted the case sheet in proof of taking treatment in IRUDAYAM Hospital Private Ltd., Nagarcoil and along with original break up bills and diagnosed reports. Further contended that the Cardiologist is not empowered to treat the patient / complainant under naturopathy-Ayur Vedic Procedures. As per discharge summery, treatment done to the complainant  during the hospitalization was S.E.C.P. (Sequential External Counter Pulsation) which is not covered by the policy under Standard Group Mediclaim Policy issued by opposite party No.1. The treatment given is unproven procedure and scientifically not acceptable as the patient is suffering from Chronic Cardiac Ailment (Triple Vessel Coronary Artery Diseases) the treatment taken by the complainant is not covered by the policy as such claim is not payable ( as per condition no.4.13 of the policy) therefore the repudiation is just and proper. This forum has no jurisdiction to entertain this case there is no deficiency in service on part of the opposite parties and prays the Forum to dismiss the complaint with costs.  

            7.  Now the points for consideration are:-

             (i). Whether there is deficiency in service on part of the opposite parties?

            (ii) Whether the repudiation passed by the opposite parties is justified?

            (iii). Whether the complainant is entitled to the reliefs sought for?

            (iv). To what relief?

           In support of the case of complainant, the complainant himself filed his evidence affidavit as P.W.No.1 and got marked Ex.A1 to A7 for the opposite parties evidence affidavit of R.W.1 K.S.R.C.S.Vidya Sagar was filed and no documents were marked on their behalf. Both parties have filed their respective written arguments. Heard the counsel for both parties.

            8. Point No.(i):-  In order to answer this point onus lies on the complainant. To prove the allegation that there is deficiency in service on part of the parties, the complainant filed his evidence affidavit and Ex:A1 to A7. Out of the said Ex:A1 to A7, A2 to A5 plays a vital role. The contents of the Ex:A3 and A4 clearly shows that the complainant / patient has followed the advice given by Dr. ETHAYARAJAN, Senior Cardiologist in IRUDAYAM Hospital Nagarkoil which is one of the Network Hospitals of the opposite parties as exhibited in Ex:A2. When the opposite parties gave right to the insured / complainant to get the medical benefits / reimburse of medical expenses as insurer / beneficiary under the GROUP MIDICLAIM POLICY, if the policy holder / insurer took treatment in any of the Network Hospitals, collecting the policy premium every month from the salary of the complainant / insurer regularly, the opposite parties are bound to consider his claim and reimburse the medical expenses as per the terms and conditions of the policy, instead they have repudiated the claim.

         The learned counsel for the opposite parties while advancing arguments vehemently contended that the “TRIPLE VESSEL CARONARY ARTERY DISEASE” is not covered by the diseases referred to in the terms and conditions of the policy. But for the reasons best known, the opposite parties did not file the policy or its copy to know about terms and conditions set out in the policy. He further argued that no ECG, X-ray, Angio Gram, or Scan etc were taken to prove said disease. The learned counsel for the opposite parties raised some objections over the treatment given by Dr. ETHAYARAJAN Cardiologist of IRUDAYAM Hospital stating that no tests were conducted for the patient in connection with TRIPLE VESSEL CORNORARY ARTERY DISEASE. Without conducting any tests how the doctor came to conclusion that the patient is suffering from TRIPLE VESSEL CARONARY ARTERY DISEASE. Therefore his diagnosis is not correct and the repudiation is correct and proper.

           The primary thing to be remembered in this case is

1. THIS IS NOT THE CASE OF MEDICAL NEGLIGENCE
2. THIS CASE IS IN CONNECTION WITH REIMBURSEMENT OF MEDICAL EXPENSES OF THE COMPLIANANT / INSURED in terms of “Group Insurance Mediclaim Policy” filed by the insured / beneficiary.
3. This case is filed by the complainant / insured employee against the order of repudiation of the claim of the complainant / insured, against the opposite parties.

           The opposite parties forgetting the nature of the case and purpose of the case raising many objections over the treatment given by the doctor. If the opposite parties suspects efficient and skill of the doctor, or suspects contents of Ex:A3 and Ex:A4 issued by Dr. ETHAYARAJAN, they are at liberty to obtain an expert opinion or appoint an investigator to find out the truth and correctness of the treatment given. But they did not obtain any expert opinion; - did not collect any reports to disprove the contents of Ex:A3 and A4. On the other hand the opposite parties reported no documents in support of their case. If the opposite parties doubted the bonafidies of the doctor they can delete the IRUDAYAM HOSPITAL from the list of Network Hospitals. But they cannot deprive the complainant from exercising his rights in getting reimbursing of his medical expenses, as per the terms of the mediclaim policy, due to their in flamed angry against the doctor.

          The learned counsel for the complainant argued that the patient / complainant is an insured person, policy was given by that opposite party no.1 in favour of complainant is a Group Mediclaim Policy admittedly ;- opposite parties are collecting the policy premiums from the salary of the complainant regularly, admittedly. It is also admitted fact that the IRUDAYAM Hospital is one of the Network Hospitals of the opposite parties (Ex:A2) and admittedly complainant took treatment in IRUDAYAM Hospital, Nagarkoil, Tamilnadu. That the complainant filed discharge summary, prescriptions and diagnosis reports issued by IRUDAYAM HOSPITAL. The complainant made his claim as per the terms and conditions of the policy along with policy copy and other documents admittedly as such the “REPUDIATION” is illegal and unjust.

          Upon hearing the arguments of the counsel for both parties and on cursory  perusal of Ex:A3 and A4 it is found that Dr.ETHAYARAJAN, Senior Cardiologist of IRUDAYAM Hospital has conducted CARDIO VASCULAR CARTOGRAM TEST, which reveals that the patient is suffering from “TRIPLE VESSEL CORONORY ARTERY DISEASE”. Therefore the doctor advised the patient to undergo 35 sittings of SEQUENTIAL EXTERNAL COUNTER PULSATION (S.E.C.P). Accordingly the patient underwent 35 sittings of S.E.C.P as advised from 16.01.2015 to 26.01.2015 and recovered from the said Ailment and was discharged on 26.01.2015. No where it is mentioned that it is an Ayurvedic treatment as alleged by opposite parties.The concerned doctor is the competent person to decide what sort of treatment is to be given to a particular patient and whether surgery is required or treatment alone is sufficient to cure the disease. Therefore the doctor has exercised his description properly, provided treatment and get him cured from the disease as such we cannot find fault that the treatment of the doctor. That the doctor has also charged Rs.1,13,700/-  towards medical expenses of the complainant they cured the said ailment has shown in Exs.A3 and A4. Therefore we are not finding fault with the doctor and his treatment as well as the genuineness of recitals Ex.A3 and A4. Under the above circumstances in the absence of expert opinion or any reports by appointing investigator of the opposite parties, the opposite parties have repudiated the claim without any valid reasons and without filing any documentary evidence and even without proceeding at least the certified copy of the policy (since it is a Group Insurance Mediclaim Policy). Therefore under the above circumstances we are of the opinion that the complainant has established that there is deficiency in service on part of the opposite parties. Accordingly this point is answered.

          9.  Point No.(ii):-  Admittedly the complainant being an employee of Lanco Industries Limited presently called as Srikalahasti Pipes Limited as insured with the opposite parties and taken the policy with UHID NO. NIC00008494791 under E-ID No. 69 bearing no.100100/46/14/8500000025 which is a Group Insurance Mediclaim Policy for the plan period from 01.04.2014 to 31.03.2015. The said policy was issued for all the employees of Lanco. The said policy and E-ID number was issued by opposite party no.1 along with document under Ex:A2 specifying the list of network hospitals providing reimbursement facility for the insurers for the treatment taken in any of the said network hospitals. The complainant took treatment in IRUDAYAM  Hospital, Nagarkoil, Tamilnadu which is one of the network hospitals, under the care of Dr.ETHAYARAJAN from 16.01.2015 to 26.01.2015. The doctor conducted CARDIO VASCULAR CARTOGRAM TEST on the complainant which reveals that the complainant is suffering from TRIPLE VESSEL CORONARY ARTERY DISEASE as such the doctor advised the complainant / insurer to undergo thirty five (35) sittings of SEQUENTIAL EXTERNAL COUNTER PULSATION (S.E.C.P). Accordingly the patient underwent 35 sittings of S.E.C.P. as advised by the doctor during the period from 16.01.2015 to 26.01.2015 by spending Rs.1,13,700/- and recovered from the Ailment later he was discharged on 26.01.2015. According to Ex:A3 and A4 given by the doctor. Thus the complainant / insured /patient follow the advice of the doctor. He neither deviated the advice of the doctor nor violated terms and conditions of the policy. The complainant / insurer rightly made his claim for reimbursement of medical expenses. His reimbursement claim is genuine. Under above circumstances we are of the opinion that the repudiation order given by the opposite parties under Ex:A5 is illegal and not justified. Accordingly this point is answered.

           11. Point No.(iii):-  In view of our discussion on point no.1 and 2 and also in view of the pleadings and evidence affidavits of both parties coupled with documentary evidence under Ex:A1 to A7 we have to state that the complainant has established that there is deficiency in service on part of the opposite parties and also the REPUDIATION (dated not visible) under Ex:A5 is not justified and the complaintant therefore is entitled to the reimbursement of medical expenses of Rs.1,13,700/- so far as the alleged other expenses of Rs.25,000/- is concerned no proof is filed to  show that the complainant incurred additional amount of Rs.25,000/. Therefore this relief is not accepted. In view of the above findings we are of the opinion that the complainant is entitled for damages and costs of the complaint also. Accordingly this point is answered.  

          12. Point No.(iv):-  In view of our discussion on point No.1 to 3, we are of the opinion that the complainant established that there is deficiency in service on part of the opposite parties, that the “REPUDIATION” passed by the opposite parties under Ex:A5 is not justified and the complainant is entitled for damages and costs of the litigation. Accordingly the complaint is to be allowed.

             In the result  the complaint is allowed in part directing the opposite parties 1 and 2 to pay a sum of Rs. 1,13,700/- (rupees one lakh thirteen thousand and seven hundred only) to the complainant along with interest @ 9% p.a. from the date of the complaint i.e. from 13.10.2015, till realization. The opposite parties also directed to pay a sum of Rs.10,000/- (rupees ten thousand only) to the complainant towards damages for causing mental agony and for deficiency in service on part of the opposite parties and the opposite parties also directed to pay a sum of Rs.2,000/- (rupees two thousand only) towards costs of the litigation. The opposite parties also further directed to comply with the order within six(6) weeks from the date of receipt of copy of this order, failing which the amount of Rs.10,000/- awarded towards damages shall also carry interest @ 9% p.a.from the date of this order,  till realization.

Dictated to the stenographer, transcribed and typed by her, corrected and pronounced by me in the Open Forum on this the 18^th day of November, 2016.

 

        Sd/-                                                                                                                     Sd/-          

Lady Member                                                                                                      President

 

WITNESSES EXAMINED ON BEHALF OF COMPLAINANT/s

 

P.W-1: A. Yerram Reddy.

 

WITNESSES EXAMINED ON BEHALF OF OPPOSITE PARTY/s

 

R.W-1: K.S.R.C.S. Vidya Sagar (Chief Affidavit filed).

 

EXHIBITS MARKED ON BEHALF OF THE COMPLAINANT/s

 

Exhibits	Description of Documents
Ex.A1.	ID Card (Photo Copy).
2.	List of Hospitals Booklet (Original).
3.	Prescriptions (Original).
4.	Diagnosis Reports (Original). From Dt: 16.01.2015 to Dt: 26.01.2015.
5.	Letter from Manager, National Insurance Company Limited,  given by Opposite Party No.1.( Photo Copy)
6.	Office copy of Legal Notice. Dt: 01.05.2015.
7.	Reply from Opposite Party No.2. Dt: 02.06.2015.

 

EXHIBITS MARKED ON BEHALF OF THE OPPOSITE PARTY/s

 

NIL

                                                                                                                    Sd/-                        

                                                                                                              President

 

            

Copies to:-     1.  The complainant.

                        2.  The opposite parties.