Andhra Pradesh

Chittoor-II at triputi

CC/28/2013

A.Trivikrama Rao - Complainant(s)

Versus

The New India Assurance Co.,Ltd., - Opp.Party(s)

M.Vijaya Sekhar

01 May 2015

ORDER

Filing Date:26.03.2013

Order Date: 01.05.2015

 

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM-II,

CHITTOOR AT TIRUPATI

 

      PRESENT: Sri.M.Ramakrishnaiah, President ,

        Smt. T.Anitha, Member

 

FRIDAY THE FIRST DAY OF MAY, TWO THOUSAND AND FIFTEEN

 

C.C.No.28/2013

 

Between

 

Sri.A.Trivikrama Rao,

S/o. late A. Srinivasa Rao,

D.No.18-4-111/13, Upstairs,

Railway Colony Extension, IInd Cross,

Tirupati.                                                                                             … Complainant

 

 

And

 

1.         The New India Assurance Co. Ltd.,

            Rep. by its Senior Divisional Manager,

            9^th Floor, Parisram Bhavan,

            Basheerbagh,

            Hyderabad.

 

2.         M/s. Good Health Plan Limited,

            rep. by its Manager – Claims,

            Plot No.49, Nagarjuna Hills,

            Punjagutta,

            Hyderabad.                                                                            …  Opposite parties.

 

 

            This complaint coming on before us for final hearing on 23.04.15 and upon perusing the complaint, written version and other relevant material papers on record and on hearing Sri.M.Vijayasekhar, counsel for the complainant, and Sri.Prem Kumar Karanam, counsel for the opposite parties, 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 C.P.Act 1986, by the complainant against the opposite parties 1 and 2 for the following reliefs 1) to direct the opposite parties to pay a sum of Rs.25,530/- being the amount payable to the complainant with interest at 24% p.a. from the date of complaint, till realization 2) to direct the opposite parties 1 and 2 to pay a sum of Rs.30,000/- towards compensation for causing mental agony to the complainant and 3) to direct the opposite parties to pay the costs of the complaint.

            2.  The brief averments in the complaint are:- That the complainant while working as Area Sales Manager in Penna Cement Industries Ltd., has entered into a contract of insurance with opposite party No.1 through his employer under the scheme of Mediclaim Insurance. His policy number is 612200/34/11/04/00000028, as per which complainant will be reimbursed for the surgeries, if any, undergone by the complainant during the period from October 2011 to October 2012. The complainant underwent surgeries for Hernia on 03.02.2012, 12.03.2012, 19.06.2012 and on 06.08.2012. That the complainant submitted his 4 claims for settlement / reimbursement of medical expenditure. The medical claims submitted by the complainant were passed for lesser amounts instead of accepting his total claims and deducted some amounts in each claim. That the complainant approached opposite parties 1 and 2 several times personally and also addressed letters through e-mails dt:29.09.2012, 21.11.2012, 04.12.2012 and 05.12.2012 and made phone calls requesting the opposite parties to settle the claims. Opposite party No.2 gave replies stating that “we will revert soon” through email dt:06.12.2012. The complainant through correspondence repeatedly stated that he will not encash the cheques for the amounts settled by opposite party, as there is foot note in the letters, that encashing the cheques amounts to acceptance of the amount settled towards the claim. As he did not receive the 2^nd page of the letter dt:07.09.2012, in which the above said foot note was not there, he has encashed the cheque for Rs.9,973/- in respect of claim No.28874 due to lack of knowledge about the foot note condition. The deductions are quite unreasonable and against the terms and conditions of the policy. Opposite parties are making the complainant to run from pillar to post by deducting the claims by not accepting the total claims made by the complainant. Opposite parties did not settle the claims so far. Therefore, it is deemed that his claims have been repudiated. Complainant gave notice on 22.12.2012 but the opposite parties neither gave reply nor settle the claim. Hence the complaint. 

            3.  Opposite party No.1 fled its written version on 22.07.2013 denying the complaint allegations parawise and further contending that the complainant being an employee in the said insured company submitted a claim No.28874 for Rs.14,873/-, another claim under claim No.28878 for Rs.12,157/-, third claim under claim No.28622 for Rs.14,406/- and last claim under claim No.36123 for Rs.7,061/-. After scrutinizing, the bills were accepted for admissible amounts such as Rs.9,973/- for the 1^st claim, Rs.9,066/- for the 2^nd claim, then Rs.12,695/- for the 3^rd claim and Rs.5,722/- for the 4^th claim. That the opposite party has processed all the claims after making deductions as per the terms and conditions of the policy and issued cheques duly mentioning the reasons for not paying certain amounts under the claims, which are not payable. There is no deficiency in service on the part of the opposite party No.1. That the request of the complainant to settle the claims without deductions are neither rejected nor repudiated by the opposite parties. Without getting reply or rejection or repudiation, the complainant rushed to the Court of Law and abused the process of law. Complaint is pre-matured and not maintainable and prays the Forum to dismiss the complaint with exemplary costs.

            4.  Opposite party No.2 filed its written version dt:05.12.2014 and denied the complaint averments parawise and further contended that one M/s. Penna Cement Industries Limited has taken a policy known as “Tailor Made Floater Group Mediclaim Policy (hospitalization benefit policy) from opposite party No.1 through their Third Party Administrator M/s. Good Health Plan Limited (opposite party No.2) for a period of one year commencing from 10.10.2011 to 09.10.2012 bearing policy No.61220034110400000028 insuring their employees hospitalization benefit policy. That the opposite parties will reimburse the medical expenditure incurred by the employees insured for the hospitalization period only subject to the terms and conditions of the policy, rest of the contents of the written version is triplicate of written version of opposite party No.1. Opposite party No.2 prays the Forum to dismiss the complaint against opposite party No.2 with exemplary costs.

            5.  The complainant and opposite parties 1 and 2 have filed their respective chief affidavits and written arguments. Exs.A1 to A12 were marked on behalf of complainant and reported no documents for the opposite parties.

            6.  Now the points for consideration are:-

            (i).  Whether the complainant is entitled for the total claims under the above

                   referred four claims?

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

            (iii)  To what relief?

            7.  Point No.(i):-  to answer this point, it is pertinent to refer the crucial contents of the complaint i.e. the complainant underwent surgeries for Hernia on 03.02.2012, 12.03.2012, 19.06.2012 and on 06.08.2012 and he claimed the medical expenses paid by him to the hospital i.e. Sagar Hospital, Tirupati, and claimed No.28874 for the 1^st operation, claim No.28878 for the 2^nd operation, claim No.28622 for the 3^rd operation and claim No.36123 for the 4^th operation.

            8.  For the first operation, the complainant presented the claim under claim No.28874 for Rs.14,873/- out of which the opposite parties have passed the claim only for Rs.9,973/- and deducted the remaining amount viz. Rs.1300/- under bill No.15/12 dt:01.01.2012 on the ground that investigation charges cannot be given; Rs.600/- bill No.81 dt:16.02.2012 on the ground that investigation charges cannot be given; Rs.1000/- under bill No.178 dt:17.04.2012 on the ground that anesthetic charges cannot be given and also Rs.2000/- under bill No.179 dt:17.04.2012 towards surgeon charges, as those bills are beyond hospitalization period and further the opposite parties contended that according to the terms and conditions of the policy, the charges only for hospitalization period will be given and the rest cannot be given, likewise, so far, as second claim No.28878 also the claim preferred is for Rs.12,157/- but the opposite parties have passed only Rs.9,066/- and the remaining amounts such as Rs.534/- under bill No.125 on the ground that bill does not contain the date; Rs.190-16 paise under bill No.390, another sum of Rs.97/- under bill No.2179, another sum of Rs.1770-89 under bill No.2135 and also another amount of Rs.500/- under bill No.147 dt:21.05.2012 on the ground that second two amounts are more than the actual rates and another amount on the ground that doctor’s name was not on the prescription and last amount on the ground that dressing charges cannot be given, so far third claim under 28622 is concerned claim is for Rs.14,407/- and the opposite parties decided to pay only Rs.12,695/- and rest of the amounts that were deducted are Rs.140/- under bill No.830; Rs.252/- under bill No.2666 dt:27.07.2012; Rs.564/- under bill No.682 dt:03.07.2012; Rs.226/- under bill No.664 dt:21.06.2012; Rs.12/- under bill No.712 dt:19.06.2012; Rs.158/- under bill No.658 dt:19.06.2012; Rs.275/- under bill No.657 dt:19.06.2012; Rs.49/- under bill No.2472 dt:06.06.2012 and Rs.35/- under bill No.552 dt:03.06.2012 on the ground that the amounts covered by all the said bills are more than the actual rates.

            9.  Regarding the fourth claim No.36123 claim is for Rs.7,061/- but the opposite parties have decided to pay Rs.5722/- only deducting the following amounts viz. Rs.600/- under bill No.12101 on the ground that there is no doctor’s advise for the said medicine; Rs.37/- under bill No.108325.08.2012; Rs.298/- under bill No.1041 dt:16.08.2012 on the ground that the amounts covered by the said bills are more than the actual rates; Rs.404-49 under bill No.950 dt:16.08.2012 on the ground that there is no prescription for the said bill.

            10.  The complainant is contending that he has made the claims only for the actual amounts he paid towards the surgical and treatment charges. Opposite parties liable to pay / reimburse the total claims but unfortunately they have deducted some amounts without any cogent reasons. The grounds for deducting those amounts are un-sustainable. Both the complainant and the opposite parties contended that the amounts incurred by the complainant for surgeries and treatment during the period from October 2011 to October 2012 are to be reimbursed by the opposite parties as per the terms and conditions of the medi-claim policy, to that extent the opposite parties are submitting. But further they are contending that as per the terms and conditions of the policy, the actual expenses incurred by the employee of the insured for the period of hospitalization with doctors advise medical bills only will be reimbursed. Accordingly the 2^nd opposite party sent a letter dt:13.09.2012 along with cheque No.712834 dt:13.09.2012 clearly mentioning the reasons for non paying the claim amounts.

            11.  Ex.A12 is the policy issued by the New India Assurance Company Ltd. i.e. opposite party No.1. The evidence affidavits and written arguments filed on behalf of opposite parties 1 and 2 shows that only amounts incurred for operation will be reimbursed and pre-investigation charges and also post-operation treatment charges will not be given as the complainant is not entitled for those amounts according to the policy. But the terms and conditions of the medi-claim policy under Ex.A12 or otherwise, first page of Ex.A12 under condition No.2.0

2.0	Following reasonable, customary & necessary expenses are reimbursable under the policy:
2.1	Room, boarding and nursing expenses as provided by the Hospital / nursing home not exceeding 1.0% of the sum insured (without cumulative bonus) per day or actual, whichever is less.
2.2	Intensive Care Unit (ICU) Intensive Cardiac Care Unit (ICCU) expenses not exceeding 2.0% of the sum insured per day, or actuals, whichever is less.
2.3	Surgeon, Anesthetist, Medical Practitioner, Consultant’s Specialist fees.
2.4	Anesthesia, Blood, Oxygen, Operation Theatre Charges, Surgical Appliances, Medicines & Drugs, Dialysis, Chemotherapy, Radiotherapy, Artificial Limbs, Cost of Prosthetic devices implanted during surgical procedure like pacemaker, relevant laboratory / diagnostic test, X-Ray and other medical expenses related to the treatment.
2.5	Pre-hospitalization medical charges up to 30 days period immediately before the insured’s admission to hospital for that illness.
2.6	Post hospitalization medical charges up to 60 days period immediately after the insured’s discharge from the hospital for that illness or injury.

                                  

            So, as per the above said conditions, pre-hospitalization medical expenses up to 30 days immediately preceding to the admission in the hospital and post hospitalization medical charges up to 60 days immediately after the discharge of the patient. The bills are very much within time. Therefore, the opposite parties cannot deny some of the bills under the guise that they are investigation charges and cannot be given etc. But, if the complainant claims any amounts which were not according to the prescriptions of the doctor, they can be excluded. In this connection, in fourth claim of the complainant bearing No.36123, an amount of Rs.600/- under bill No.12101 and Rs.404-49 under bill No.950 dt:16.08.2012, totaling a sum of Rs.1004-49 can be excluded from the total claim. Thus under fourth claim, the complainant is entitled to a sum of Rs.6056-51/- which is rounded up to Rs.6057/-. Thus the complainant is entitled to the total claims under first, second and third claims and a sum of Rs.6057/- for the fourth claim after excluding Rs.1004/- under the two bills referred to above.

            12.  The complainant has admitted that he has encashed the cheque for Rs.9,973/- under claim No.28874 for a sum of Rs.14,873/- because he has not received the second page of the letter sent by the opposite parties, in which a condition is mentioned by the opposite parties that encashing the cheques amounts to acceptance of the claims settled. The complainant is entitled for total sum of Rs.14,873/- excluding Rs.9,973/- i.e. balance of Rs.4,900/-. The complainant has not encashed the remaining cheques, as such the total amounts are to be given by the opposite parties for the said three claims altogether Rs.33,625/- + balance amount of Rs.4,900/- in respect of first claim, totaling a sum of Rs.38,525/-, as all the claims are within the period covered by the policy and the terms and conditions thereof. Accordingly this point is answered.

            13.  Point No.(ii):-  to answer this point, we have to state that the opposite parties having accepted the policy under Ex.A12, which was issued in the name of  complainant, admitting the terms of the policy and its period from 10.10.2011 to 09.10.2012, admitting the surgeries also within the said period of one year, during which the policy is in force and is enforceable, there are no grounds to deduct the amounts from the claims of the complainant / policy holder. The purpose of medi-claims will be very much defeated, if the opposite parties go on deducting the amounts at their whims and fancies. The opposite parties are not supposed to deduct the amounts out of genuine claims made by the policy holder / complainant. The opposite parties have not denied or disputed the surgeries that were underwent by the complainant. Denying any claim or part thereof knowing prettily that those claims are within the period governed by the policy and very much covered by the terms and conditions of the policy, certainly amounts to deficiency in service. There is no stipulation for the surgeries that the opposite parties will pass the claims only for the first surgery or second surgery or third surgery etc., when the surgeries were infected and continued to go for surgery number of times for removal of such infections, the expenditure incurred by the complainant / policy holder are to be reimbursed by the opposite parties. There is deficiency in service on the part of opposite parties in passing / accepting  part of the claims preferred by the complainant, in pursuance of the medi-claim policy under Ex.A12. Another contention of the opposite parties that since they have neither rejected the claims nor repudiated the claims made by the complainant, the complainant is not supposed to file the case and the complaint on hand is pre-mature and cannot be sustained. The claims were made within stipulated period of one year, as mentioned in the policy under Ex.A12 and the fourth claim No.36123 submitted to the opposite parties on 13.09.2012 but alleged that there is no response from the opposite parties till the date of complaint, which was presented on 26.03.2013. It clearly establishes that the opposite parties maintained silence for about six months after making the claims inspite of complainant’s correspondence that he is not going to encash the cheques for the second, third and fourth claims and requesting the opposite parties to settle the total claims as prayed for. All these circumstances, clearly establishes that there is deficiency in service on the part of opposite parties. Accordingly this point is answered.

            14.  Point No.(iii):-  in view of our holding on points 1 and 2, we are of the opinion that there is deficiency in service on the part of opposite parties 1 and 2 and that the complainant is entitled to all the four claims, for the total amounts excluding the amounts already encashed in a sum of Rs.9,973/- and Rs.1004/- out of fourth claim and the opposite parties 1 and 2 are jointly and severally liable to reimburse the remaining amount of Rs.38,525/- with interest and complaint is to be allowed accordingly.

            In the result, the complaint is allowed directing the opposite parties 1 and 2 jointly and severally to pay a sum of Rs.38,525/- (Rupees thirty eight thousand five hundred and twenty five only) to the complainant with interest at 9% p.a. from the date of complaint, till realization. That the opposite parties 1 and 2 also jointly and severally directed to pay a sum of Rs.5,000/- (Rupees five thousand only) towards compensation for the mental agony caused to the complainant and also directed to pay Rs.2,000/- (Rupees two thousand only) towards costs of the complaint. The opposite parties 1 and 2 further directed to comply with the orders within six (6) weeks from the date of receipt of copy of order, failing which the compensation amount of Rs.5,000/- also shall carry interest at 9% p.a. from the date of complaint, till realization.

Typed to dictation by the stenographer, corrected by me and pronounced in the Open Forum this the 1^st day of May, 2015.   

 

       Sd/-                                                                                                                      Sd/-                                                                           

Lady Member                                                                                                      President

 

APPENDIX OF EVIDENCE

WITNESS EXAMINED ON BOTH SIDES

 

 

 

PW-1: A.Trivikrama Rao (Chief Affidavit filed).

 

RW-1: E.Jayaramaiah (Chief Affidavit filed).

Rw-2:  P.S.Murthy (Chief Affidavit filed).

 

EXHIBITS MARKED ON BEHALF OF THE COMPLAINANT/S

 

Exhibits	Description of Documents
Ex.A1.	A photo copy of Certificate issued by Sr. Manager, (Admn.) Penna Cement Industries Limited., Hyderabad with regard to employment of the Complainant. Dt: 24.01.2012.
2.	Attested photo copy of Health Card ID No.377, issued by the New India assurance Co., Ltd., through Good Health Plan Limited, Hyderabad. Dt: 26.03.2013.
3.	Claim letter No.28874 for the operation Dt. 03.02.2012 along with Claim forms expenses statement and deductions by Opposite Party No.2. Dt: 07.09.2012.

 

 

4.	Claim letter No.28878, for the operation Dt. 12.03.2012 along with Claim forms expenses statement and deductions by Opposite Party No.2. Dt: 13.09.2012.
5.	Claim letter No.28622 for the operation Dt. 19.06.2012 along with Claim forms expenses statement and deductions by Opposite Party No.2. Dt: 06.11.2012.
6.	Claim letter No.36123 for the operation Dt. 06.08.2012 along with Claim forms expenses statement and deductions by Opposite Party No.2. Dt: 13.09.2012.
7.	Bunch of mail corresponding copies between Complainant and OP2.
8.	Final reminder letter Dt.04.12.2012 sent to Opposite Party No.2 through mail.
9.	Final remainder letter Dt: 05.12.2012 sent to Opposite Party No.2 through mail as well as through Courier.
10.	Dt: 12.12.2012 Opposite Party No.2 sent reply for the above.
11.	Legal Notice Dt: 22/12/2012 filed on behalf of the Complainant.
12.	Mediclaim policy Booklet (Terms and Conditions) filed on behalf of the Complainant.

 

EXHIBITS MARKED ON BEHALF OF THE   RESPONDENT/S

 

-  NIL -

 

                                                                                                                              

                                                                                                                                                                 Sd/-

                                                                                                                President

            

               // TRUE COPY //

// BY ORDER //

 

 

Head Clerk/Sheristadar,

              Dist. Consumer Forum-II, Tirupati.

                                                             

 

 

Copies to:-     1. The Complainant.

                        2. The opposite parties.