O R D E R
(By Mr. D.Shanker Rao, Member)
1. The brief facts set-out in the complaint are that the complainant is having SB account bearing No.59610025181678 with the branch of opposite party No.2 bank and he has been member of AB Arogyadaan bearing ID card No.050400/48/11/41/00000225, branch Cd.596, BA 1 No.14233, GHPL-UAB-ARG-27456-1 valid from 21-9-2011 to 20-9-2012. It is mediclaim plan started by opposite party No.2 has tie-up with opposite party No.1 insurance company. The complainant joined in the mediclaim plan and regularly paying the policy amount for last six years with total claim coverage of Rs.5,00,000/- (Rupees Five lakhs only).
The complainant suffered from chest pain and admitted in Yashoda Hospital secunderabad on 11-6-2012 and he was operated a “Cardiothoracic Minimal Access Surgery” on 16-6-2012 and discharged on 18-6-2012. At the time of hospitalization, the complaint furnished the AB Arogyadaan card as the Yashodha Hospital was covered under Good Health plan Ltd (GHPL) selected Hospitals. At the time of discharge, the complainant was charged the total amount of Rs.2,97,100/- under various heads of surgery charges for Rs.1,91,250/- attendants room retained for Rs.11,850/- and minimally invasive charges for Rs.94,000/-. Out of the total amount, the opposite party No.1 company paid only for Rs.1,91,250/- and the balance amount of Rs.1,05,850/- was collected from the complainant. As per Good Health plan Ltd of AB Arogydaan scheme, the complainant is entitled total hospitalization charges, Inspite of requests and intimation, the opposite party No.1 company did not respond which clearly shows the deficiency of service and claiming against opposite parties 1 and 2 jointly and severally for the payment of Rs.1,05,850/- with 18% interest per annum from 19-6-2012 till realisation and compensation of Rs.50,000/-.
2. The opposite party No.1 company filed its counter and stating that the complainant with ID No.GHPL-UAB-ARG-2746-1 under the Arogyadaan scheme of opposite party NO.2 obtained floater mediclaim policy on 18-9-2008 for sum insured Rs.5,00,000/- and renewed three time and fourth year policy bearing No.050400/48/11/41/00000225 valid from 21-9-2011 to 20-9-2012 for sum insured Rs.5,00,000/-. The opposite party No.1 company has appointed GOOD HEALTH PLAN LIMITED’ Hyderabad as third party administrator and authorize to settle the claims under the policy. He is necessary party to the case, hence complaint is bad for non – joinder of the necessary party and complaint is liable to be dismissed.
The liability of the opposite party No.1 company is to be strictly governed by the terms, conditions, exclusions and definitions under above mediclaim policy and relevant law and breach of which does not make liable for any compensation. During fourth year of the policy, the complainant approached cashless authorization at Yashoda Hospital Secunderabad and admitted on 11-6-2012, operated on 15-6-2012 and discharged on 18-6-2012. As per agreed PPN tariffs by GIPSA the maximum amount that can be payable towards CABG is Rs.1,91,250/-. Accordingly, the third party administrator has settled the same for Rs.1,91,250/- on vide NEFT No.12988928. The complainant so far not approached the opposite party No.1 or third party administrator and made any claim. The complainant directly filed complaint prematurely. Hence no question of rendering deficiency services. The complainant is not eligible for any amount except Rs.1,91,250/- as per terms and conditions of the policy and scheme. The complainant as already accepted and gave consent for settlement of claim at Rs.1,91,250/- as per GIPSA guidelines and not disputed the settlement of claim. Therefore the present claim of Rs.1,05,850/- with interest and compensation does not arise and the complaint is liable to be dismissed with costs.
3. The opposite party No.2 bank is remained set-exparte throughout the proceedings.
4. During enquiry, the complainant S.Sampath Reddy has field his affidavit as PW1 evidence and marked Ex.A1 to A6 documents and closed his evidence. The opposite party No.1 company has filed affidavit of its Deputy Manager Nanchari Narsaiah as RW1 evidence and marked Ex.B1 and B2 documents and closed its evidence.
5. Heard arguments.
6. The points for consideration are :
1) Whether there is any deficiency service on the part of opposite parties in restricting the claim of Rs.1,91,250/- instead of payment for Rs.2,97,100/- under mediclaim policy?
2) To what relief?
7. POINTS 1 & 2: It is not disputed that the complainant is being SB account holder bearing No.59610025181678 with the bank of opposite party No.2 and having membership of AB Arogyadaan scheme bearing ID card No.050400/48/11/41/00000225 branch Cd.596, BA 1 No.14233, GHPL-UAB-ARG-27456-1 for sum insured Rs.5,00,000/- valid form 21-9-2011 to 20-9-2012 in Ex.A2 and A6 which is mediclaim plan under tie-up floated by opposite party No.1 company. It is also not disputed that the opposite party No.1 company has appointed Good Health Plan Limited, Hyderabad as third party administrator and authorize to settle the claims under the policy. It is also not disputed that the Yashodha Hospital is one of the listed hospitals which notified by Good Health Plan Limited Hyderabad for reimbursement of hospitalization expenses as per the AB Arogyadhaan scheme policy as opted in Ex.A2, A6 and Ex.B2. It is also not disputed that the complainant has suffered with chest pain and admitted in Yashodha Hospital at Secunderabad on 11-6-2012 and he was operated for a cardiothoracic minimal access surgery and discharged from hospital on 18-6-2012.
The contention of the complainant is that the total hospitalization expenses under heads of Minimally invasive charges for Rs.94,000/-, attendants room retained for Rs.11,850/- and surgery charges for Rs.1,91,250/- were not reimbursed but confined the claim and paid Rs.1,91,250/- only is sheer negligence and deficiency of services on the part of opposite party No.1 company. Further the counsel for the complainant vehemently argued that the complainant is entitled the balance amount of Rs.1,05,850/- as per Good Health Plan limited in Ex.A6 and AB Arogyadaan scheme terms and conditions in Ex.B2.
The version of the opposite party No.1 company is that the Good Health plan limited Hyderabad is authorized and settled the claim of complainant for Rs.1,91,250/- as per PPN tariff by GIPSA under cashless procedure to the authorities of Yashodha Hospital. Therefore the dispute is raised between the complainant and opposite party No.1 company for the reimbursement of the balance amount of Rs.1,05,850/- to the complainant. Admittedly the mediclaim policy was issued in Ex.A6 to the complainant as per AB Arogyadaan scheme in Ex.B2 by the opposite party NO.1 company. There is no dispute over the Ex.A6 and Ex.B2 documents. Hence the terms and conditions of Ex.A6 policy and Ex.B2 scheme could operate over the settlement of claim. The terms and conditions mentioned in the Ex.A6 and the procedure, Rules, Regulations, features and exclusions mentioned in Ex.B2 (document in 12 pages) are one and the same. Hence the Ex.A6 is herewith perused and reproducing the relevant condition herein for arrival of conclusion in settlement of the instant case.
CONDITON No.5.1 CLAUSE 1, 2 AND d. OF THE Ex.A6 MEDICLAIM POLICY
1. Room rent and nursing Expenses : not exceeding 1% of the sum insured per day
or actual amount, whichever is less.
2. ICU Expenses : not exceeding 2% of the sum insured per
day or actual amount whichever is less.
d. For specified major surgeries : 80% of S.I. subject to Rs.4,00,000/- Cardiac / Cancer / Brain tumor / Pace Maker implantation / Hip replacement / Knee joint replacement
According to Ex.A6 it is clear that for special major surgeries 80% of the sum insured subject to Rs.4,00,000/- Cardiac / Cancer / Brain Tumor / Pace Maker implantation / Hip replacement / Knee joint replacement and in addition to that room rent and nursing expenses not exceeding 1% of the sum insured and in case of ICU expenses not exceeding 2% of the sum insured.
The claim of the complainant is restricted for Rs.1,91,250/- instead of payment for Rs.2,97,100/-. Hence the burden to be discharged by the opposite party No.1 company, how the claim was settled for Rs.1,91,250/- instead of Rs.2,97,100/-. The opposite party No.1 company has relied upon Ex.B1 which is a letter addressed by Good Health plan limited Hyderabad who appointed as third party administrator and settled the claim. The Ex.B1 speaks only that the claim was settled as per agreed PPN tariff by GIPSA under cashless procedure.
It is totally silent about the claim of Rs.94,000/- under head of minimally invasive charges and Rs.11,850/- under attendants room retained and why they were not considered along with the surgery charges for Rs.1,91,250/-. Therefore the Ex.B1 is not at all helpful documentary evidence for the contention of the opposite party No.1 company and failed to discharged its burden of proof in restricting the claim of complainant for Rs.1,91,250/- instead of settling the claim for Rs.2,97,100/- which is eligible as per condition No.5.1 and clause 1, 2 and d of the Ex.A6 mediclaim policy.
Further the Good Health plan limited Hyderabad is third party administrator appointed by opposite party No.1 company and authorized for settlement of the claims under Aarogyadaan scheme. The relationship among the opposite party No.1 company, complainant and Good Health plan limited only by virtue of Ex.A6 mediclaim policy. Hence the act of Good Health plan limited is nothing but act of the opposite party No.1 company therefore the Good Health plan limited Hyderabad is no need to be party to the present proceedings. No doubt, there is a cause of action arise between the parties of the complaint since the claim is restricted. Hence there is no stuff in the contention of the opposite party No.1 company that the complaint is prematured.
The opposite party No.2 is a bank and introduce the AB Arogyadaan scheme to its SB account holders under tie-up with the opposite party No.1 insurance company. Hence we are considered opinion that the opposite party No.2 is nominal party to the present proceedings and not for any reliefs in the circumstances of the case. Therefore the case against opposite party No.2 is dismissed without costs.
The complainant has not produced any evidence how he sustained loss though pleaded for Rs.50,000/- as compensation. Hence the complainant is not entitled for any compensation except for receiving of balance amount of claim of Rs.1,05,850/- with interest along with costs of the Rs.2,000/-.
In view of aforesaid discussion and findings, there is deficiency of service on the part of the opposite party No.1 company and liable to pay Rs.1,05,850/- with 9% interest along with costs of Rs.2,000/- to the complainant.
IN THE RESULT, the complaint is allowed partly as under:
- The opposite party No.1 company is directed to pay Rs.1,05,850/- (Rupees One lakh five thousand eighty hundred and fifty only) towards balance amount under Ex.A6 mediclaim with 9% interest per annum from 19-6-2012 i.e. the next day after the date of settlement till ralisation to the complainant.
- The opposite party No.1 company also directed to pay Rs.2,000/- (Rupees Two thousand only) towards costs of the complaint.
Typed to dictation, corrected and pronounced by the Member in Open Forum on this the 22nd day of February 2013.
