Date of filing: 7.4.2014.
Date of disposal: 25.11.2014.
BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM - II:
VIJAYAWADA, KRISHNA DISTRICT
Present: SMT N. TRIPURA SUNDARI, B. COM., B. L., PRESIDENT (FAC)
SRI S.SREERAM, B.COM., B.A., B.L., MEMBER
TUESDAY, THE 25TH DAY OF NOVEMBER, 2014.
C.C.No.80 of 2014
Between:
Bikkina Venkatgeswara Rao, S/o Late Marayya, Hindu, 62 years, Business and Properties, R/o Door No.30-6-4, Durga Agraharam, L.Pullaiah Street, Vijayawada.
. … Complainant.
AND
1. The New India Assurance Company Limited, Rep., by its Authorized Person, DO- 610200, Parishram Bhavan, 9th Floor, Door No.5-9-58/B, Basheerbagh, Hyderabad – 500 004.
2. Good Health Plan Limited, Rep., by its Authorized Person, Plot No.49, Nagarjuna Hills, Panjagutta, Hyderabad – 500 082.
. … Opposite Parties.
This complaint coming on before the Forum for final hearing on 12.11.2014, in the presence of Sri K.Satya Sai Kumar, Advocate for complainant and Sri V.V.S.Sai Babu, Advocate for opposite party No.1 and opposite party No.2 remained absent and upon perusing the material available on record, this Forum delivers the following:
O R D E R
(Delivered by Hon’ble President (FAC) Smt N. Tripura Sundari)
This complaint is filed under Section 12 of the Consumer Protection Act, 1986.
The averments of the complaint are in brief:
1. the complainant is having savings bank account of Andhra Bank, Seetharampuram Branch, Vijayawada and also credit card facility. The 1st opposite party had announced a medi-claim policy to the customers who are having Andhra Bank Credit card. So the complainant obtained mediclaim policy from the 1st opposite party. The 1st opposite party had tie up with the 2nd opposite party for reimbursement of claim of Andhra Bank credit card scheme holder under the medi-claim. The complainant and his wife joined in the Group medi-claim policy in the year 1999 by paying yearly subscription to a tune of Rs.2,846/- to the 1st opposite party through his Andhra Bank credit card initially for a sum of Rs.50,000/- each. Subsequently in the year 2008 the 1st opposite party enhanced the sum to a tune of Rs.1,00,000/- each and the yearly premium of Rs.8,878/- was paid by the complainant to the 1st opposite party. The complainant and his wife paid an amount of Rs.9,472/- towards yearly group medi-claim policy for Andhra Bank credit card holders hospitalization benefit policy for the period from 1.4.2013 to 31.3.2014. While so on 4.1.2014 the complainant joined in Vijaya Super Specialty Hospital, Vijayawada for severe pain in the stomach which are diagnosed as acute pancreatitis and underwent treatment and discharged on 8.1.2014. As per the policy the 1st opposite party has to pay the treatment charges and after post hospitalization treatment which is upto 60 days. “The complainant claimed an amount of Rs.31,112.07ps for hospitalization along with investigation pharmacy and other bills relating to him. After discharges from the hospital he had taken medicines and treatment within 60 days and claimed an amount of Rs.3,103/- and Rs.3,445/- towards post hospitalization. The 2nd opposite party rejected an amount of Rs.2,357/- on the ground of professional charges and the complainant claimed only pharmacy bills. In total the 2nd opposite party withheld the amount of Rs.5,467/- without any proper reasons and basis which amounts to deficiency in service. Hence the complainant is constrained to filed this complaint against the opposite parties praying the Forum to direct the opposite parties to repay the total deducted amount of Rs.5,467/- to the complainant, to pay legal expenses of Rs.2,000/-, to pay Rs.5,000/- towards compensation and to pay costs.
2. The 2nd opposite party remained absent and the 1st opposite party filed its version.
The version of the 1st opposite party is in brief:
The 1st opposite party denied all the allegations of the complaint and submitted that the complainant submitted all the material papers to the 2nd opposite party and they had settled the claim amount as per terms and conditions of policy. The complainant is not entitled Rs.3,110/- and Rs.2,357/- totaling Rs.5,467/- as claimed by the complainant. The 2nd opposite party has already informed the same to the complainant. Hence there is no deficiency of service on the part of the 1st opposite party and prayed to dismiss the complaint with costs.
3. On behalf of the complainant he gave his affidavit and got marked Ex.A.1 to Ex.A.12. On behalf of the 1st opposite party Sri B.A.Nelson Babu, Manager filed his affidavit and got marked Ex.B.1 to Ex.B.5.
4. Heard the perused.
5. Now the points that arise for consideration in this complaint are:
1. Whether there is any deficiency in service on the part of the opposite parties
towards the complainant in not repay the deducted amount to the complainant?
2. If so is the complainant entitled for any relief?
3. To what relief the complainant is entitled?
POINTS 1 AND 2:-
6. On perusing the documents on hand it is an admitted fact that the complainant and his wife obtained group medical claim policy from the year 2007 to 2013 from the opposite party and paid the premiums for the insurance amount of Rs.50,000/- each in first year and it was revised to Rs.1,00,000/- each from the next term and renewed the same up to till 1.4.2013 under Ex.A.1 to Ex.A.3. The 1st complainant obtained medi-claim policy from the 1st opposite party for reimbursement of claim of Andhra Bank Credit card holder under the above said medi-claim policy. The complainant and his wife paid an amount of Rs.9,472/- towards yearly group medi-claim policy for Andhra Bank credit card holders hospitalization benefit policy for the period from 1.4.2013 to 31.3.2014. The complainant joined in Vijay Super Specialty Hospital, Vijayawada on 4.1.2014 for severe pain in the stomach and it was diagnosed as acute pancreatitis and underwent treatment and discharged on 8.1.2014. Then the complainant made a claim with the opposite parties for reimbursement of hospitalization charges under Ex.A.4 along with medical bills and hospital and diagnosis charges under Ex.A.5 and Ex.A.6. The complainant claimed an amount of Rs.31,112/- but the opposite parties settled the claim for Rs.27,997/-. After discharge from the hospital the complainant had taken medicines under treatment within 60 days and claimed an amount of Rs.3,103/- and Rs.3,445/- under Ex.A.9 to Ex.A.11 towards post hospitalization. The 2nd opposite party rejected an amount of Rs.2,357/- of professional charges. As per the complainant the opposite parties withheld an amount of Rs.5,467/- without proper reasons. As per opposite parties the complainant submitted all the material papers to the opposite parties and they had settled the claim amount as per terms and conditions under Ex.B.1 of the policy. The 2nd opposite party already informed the same to the complainant under Ex.B.2. Under the terms and conditions of the policy the opposite parties settled the claim for Rs.27,997/- after deductions of amount of Rs.3,115/-. The insured submitted three post claims amount of Rs.3,103/- and Rs.3,455/- the claim was processed and settle for Rs.3,103/- and Rs.1,093/-. As per the policy, room, boarding and nursing expenses provided by the hospital or nursing home are payable not exceeding 1.0% of the sum insured per day or actual whichever is less. Intensive care unit, intensive cardiac care unit expenses not exceeding 2% of the sum insured per day or actual whichever is less. When the assured admitted in hospital opts room rent higher than the liability than the amount payable under terms and conditions of 2.3 (provisional fees like surgeon, anesthetist, consultation charges etc.,) and 2.4 (includes expenses other than policy terms of 2.1 and 2.2). 2.1 reads as follows: room, boarding and nursing expenses as provided by the hospital not exceeding 1.0% of the sum insured per day or actual, whichever is less. 2.2 reads as follows: intensive care unit (ICU)/Intensive Cardiac Care unit (ICCU) expenses not exceeding 2.0% of the sum insured per day, or actual, whichever is less. 2.3 reads as follows: like anesthetist, oxygen OT charges, medicines, investigation by diagnostic charges etc., shall be at the rate applicable to the entitled room rent category. In this case the insured opts for a room with rent higher than the entitled category as under (2.1 room rent). Room rent includes, room rent charges nursing charges and boarding charges. The assured sum is Rs.1,00,000/- so room rent liability is Rs.1,000/- per day and for ICU is Rs.2,000/- per day. Insured opted room rent of Rs.1,100/- (more than liability). Hence proportionate applies. Proportionate = difference of eligibility RR and opted room rent = 100/1100 = 9% of proportionate applied on 2.3 and 2.4.
Computation:
Heads | Claim amount | Dedu Amount | Paid Amt | Remarks |
Room rent | 4,400 | 400 | 4,000 | 1% of sum insured for 4 days |
Professional fee | 4,750 | 428 | 4322 | Proportionate deduction 9% |
Investigations | 10720 | 1465 | 9255 | No reports for X-ray PA view, ECG and X-ray abdomen, 9% proportionate deduction. |
Pharmacy | 10654 | 234 | 10420 | Easy fix, glucostrips, N/P |
Others | 588 | 588 | 0 | Casuality charges, N/P |
Total | 31112 | 3115 | 27997 | |
The claim was settled as above as per policy.
7. We noted the said statements of the opposite parties in the terms and conditions of the policy. The complainant submitted two documents stating that he obtained medi-claim policy from the opposite parties from 1.4.2005 and it is renewed up to date under the terms and conditions of the policy. Under Clause 2 definitions in Group mediclaim insurance policy reads as follows: clause 2.1: Hospital/nursing home, means any institution in India established for indoor care and treatment of sickness and injuries. Clause 2.1.1: the term “hospital/nursing home” shall not include an establishment which is a place of rest, a place for the aged, a place for drug-addicts or place of alcoholics, a hotel or a similar place. Clause 2.2: Surgical operation means manual and/or operative produces for correction of deformities and defects repair of injuries, diagnosis and cure of diseases, relief of suffering and prolongation of life. Clause 2.3: Expenses on hospitalization for minimum period 24 hours are admissible. However this time limit is not applied to specific treatments i.e., dialysis, chemotherapy, radiotherapy, eye surgery, dental surgery, lithotripsy (kidney stone removal) D & C, tonsillectomy taken in the hospital/nursing home and the insured is discharged on the same day, the treatment will be considered to be taken under hospitalization benefit. The opposite parties say that the document filed by the complainant is not valid according to law the complainant has not filed all the papers of the document and the document is not related to subject type of policy and particular period of policy. Hence the document filed by the complainant is not valid as per law. Therefore we hold that the opposite parties settle the claim as per terms and conditions of the policy relating to the present period of policy. Hence there is no deficiency in service on the part of the opposite parties and the opposite parties are not liable to pay the claim amount. Accordingly these points are answered.
POINT No.3:-
8. In the result, this complaint is dismissed without costs.
Dictated to the Stenographer K.Sivaram Prasad, transcribed by him, corrected by me and pronounced by us in the open Forum, this the 25th day of November, 2014.
PRESIDENT(FAC) MEMBER
Appendix of evidence
Witnesses examined
For the complainant: For the opposite parties:
P.W.1 B.Venkateswara Rao D.W.1 B.A.Nelson Babu,
Complainant, 1st opposite party
(by affidavit) (by affidavit)
Documents marked
On behalf of the complainant:
Ex.A.1 01.04.2007 Schedule issued by the 1st opposite party.
Ex.A.2 28.04.2008 Schedule issued by the 1st opposite party.
Ex.A.3 05.04.2013 Copy of Group Mediclaim Policy for Andhra Bank Credit Card Holders Hospitalization Benefit Policy Schedule.
Ex.A.4 17.01.2014 Photocopy of claim form.
Ex.A.5 08.01.2014 Photocopy of IP-Final Bill (Detailed) issued by Vijaya Super Specialty Hospital, Vijayawada.
Ex.A.6 06.01.2014 Photocopies of Diagnostic Requisition issued by Global Multi Specialty Hospital, Vijayawada and Investigation
Receipts issued by Vijaya Super Specialty Hospital, Vijayawada.
Ex.A.7 03.03.2014 Photocopy of the settlement and deduction details below for reference statement by the 2nd opposite party.
Ex.A.8 02.03.2014 Photocopy of claim form.
Ex.A.9 02.03.2014 Photocopy of tax invoice issued by Kalpana Medical Cum Fancy Centre, Vijayawada.
Ex.A.10 28.02.2014 Photocopy of receipt issued by Vijaya Super Specialty Hospital, Vijayawada.
Ex.A.11 . . Photocopies of Pharmacy bill break up and consultation bill break up.
Ex.A.12 18.03.2014 Copy of E-mail statement of the 2nd opposite party showing the deducted amount without any particulars as claimed by the complainant..
On behalf of the opposite parties:
Ex.B.1 05.04.2013 Copy of Group Mediclaim Policy for Andhra Bank Credit
Card Holders Hospitalization Benefit Policy Schedule.
Ex.B.2 . . Copy of letter from the 2nd opposite party to the complainant.
Ex.B.3 21.03.2014 Copy of letter from the 2nd opposite party to the complainant.
Ex.B.4 21.03.2014 Copy of letter from the 2nd opposite party to the complainant.
Ex.B.5 20.06.2014 Photocopy of letter from the 2nd opposite party to the 1st opposite party.
PRESIDENT(FAC)
