Andhra Pradesh

Guntur

CC/214/2010

Rayapudi Bhagya Lakshmi, - Complainant(s)

Versus

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

Sri P.V.Ramana

19 May 2011

ORDER

BEFORE THE DISTRICT CONSUMER FORUM
GUNTUR
 
Complaint Case No. CC/214/2010
 
1. Rayapudi Bhagya Lakshmi,
W/o. R.V.Ram Prasad, R/o. Door No.1-42-22, Nazarpet, Tenali, Guntur District
 
BEFORE: 
 HON'BLE MR. A Hazarath Rao PRESIDENT
 HON'BLE MS. SMT T. SUNEETHA, M.S.W., B.L., MEMBER
 HONORABLE Sri M.V.L. Radha Krishna Murthy Member
 
For the Complainant:
For the Opp. Party:
ORDER

   This complaint coming up before us for final hearing on                      13-05-11 in the presence of Sri P.V.Ramana, advocate for complainant and of Sri J.Nageswara Rao, advocate for opposite party, upon perusing the material on record, hearing both sides and having stood over till this day for consideration, this Forum made the following: 

 

O R D E R

Per Sri M.V.L.Radha Krishna Murthy, Member:

                This complaint is filed under section 12 of the Consumer Protection Act, 1986 praying to award Rs.40,419/- (comprising of policy claim amount Rs.31,419/-, for mental agony Rs.3000/-, towards compensation Rs.3000/- and towards legal expenses Rs.3000/-) with interest @ 12% p.a. from the date of complaint till realization in favour of complainant against the opposite party.

 

The averments of complaint in brief are as follows:

 

                The complainant and her husband took a family/mediclaim policy from the opposite party in the year 2000 and it was renewed continuously without any lapse. The opposite party collected premium of Rs.5043/- from complainant and issued policy, which is valid till                  15-10-09.  The family members of policy consists 3 members i.e., complainant, her husband and daughter respectively.  The sum assured for each individual is Rs.75,000/-.  Since beginning of policy, the complainant and her family members never made any claim.  The opposite party also granted no claim bonus whenever the policy was renewed.  The opposite party has business tie-up with Heritage Health Services Pvt. Ltd., Hyderabad.  The opposite party settles the claims after due verification and scrutiny made by the above Heritage Health Services Pvt. Ltd.

                The complainant sustained fracture injury on her left elbow region on 25-03-09 due to a slip while attending domestic work.  She was admitted in Amrutha Nursing Home, Tenali, where the doctor who is orthopedic surgeon advised the complainant to undergo some investigations to diagnose the correct facts. Accordingly the complainant underwent investigations and X-Ray. Basing on the investigation reports the doctor advised the complainant for surgery, for removal of radial bone from the elbow.  Accordingly the doctor conducted operation on 25-03-09. The complainant got sutures (surgical) on her left hand.  The doctor collected fee for operation along with operation medicines expenditure from the complainant and the hospital authorities issued medical certificates and discharge summary.  The medical shop also issued bills for the medicines.  The complainant was treated as inpatient in the said hospital upto           05-04-09 and later she was treated as outpatient for a period of one month. After completion of post operative treatment there was reunion of fracture. The complainant also underwent some physiotherapy exercises for stretching her left hand.

                The complainant submitted the claim form along with all bills to opposite party.  The complainant claimed Rs.31,419/- towards hospitalization charges with co-related bills. The opposite party received the same and forwarded the claim to Heritage Health Services Pvt. Ltd., Hyderabad.  Subsequently they demanded for submission of X-Ray.  Accordingly the complaint submitted X-Ray to opposite party and also obtained acknowledgement from opposite party.  Inspite of several requests made by complainant, the opposite party failed to settle the claim.  The complainant made several representations to Heritage Health Services Pvt. Ltd. as well as opposite party.  Ultimately the Heritage Health Services Pvt. Ltd. issued a letter                dt.02-02-10 stating that the claim is not fit for settlement due to discrepancies in medical bills.  The opposite party neither issued repudiation letter nor settled the claim. Hence, the complaint.      

 

The opposite party filed its version, which is brief as follows:

 

                The insured R.V.Ram Prasad, submitted claim form stating that his wife suffered fracture injuries on 25-04-09 and the same was detected on 25-04-09, that the complainant was admitted in the hospital on 25-03-09 and was discharged on 05-04-09.  He further claimed an amount of Rs.19,200/- towards room rent, doctors fee etc. and Rs.12,219/- towards medicines/OT charges etc. total Rs.31,419/-.  The opposite party referred it to Heritage Health Services Pvt. Ltd. for settlement.  Inspite of repeated demands/requests made by Heritage Health Services Pvt. Ltd., the complainant failed to furnish copies of case sheet, medical hospital receipts, X-Rays obtained prior to and subsequent to the alleged operation.  On perusal of records, it is observed that the claim of complainant is doubtful and the complainant wantonly resorted to non disclosure of material information and it is further observed that insured was asked by Heritage Health Services Pvt. Ltd. to cause production of

  1. X-Ray films taken before and after surgery.    
  2. First consultation slipand proer bills for the payments made to hospital
  3. Copy of case sheet/indoor case receipt.

 

                In reply to that the insured furnished the x-copies and some documents, which consists so many differences.  Further the husband of complainant failed to furnish X-Ray films pertaining to the injury.  However he furnished illegible and mutilated X-Ray films, which does not carry name or date.  The complainant is said to have been inpatient for 12 days, the complainant has failed to submit case sheet for that period. The bill for Rs.25,600/- was dt.25-03-09, which happens the date of admission and also the bill amount as on the date of discharge.  It is not known to opposite party as to how the complainant anticipated the total amount of bill payable by the time of discharge will be Rs.25,600/- and how can the insured pay the exact amount at the beginning itself.  The pharmacy bills submitted by insured are not in order. The bill numbers and dates are not co-related and in such circumstances, the repudiation of claim is valid.  The insured being the husband of complainant cannot file the claim application.  The complainant is not a consumer and the present complaint is not maintainable.  Hence, the complaint may be dismissed with exemplary costs.

 

                The complainant and opposite party filed their respective affidavits in support of their respective contentions reiterating the same.  

                On behalf of complainant Ex.A1 to A10 are marked.  No documents are marked on behalf of opposite party.

 

Now the points for consideration are

  1. Whether there is any deficiency of service on the part of opposite party?
  2. To what relief the complainant is entitled to?

 

POINT No.1

                It is not in dispute that the opposite party has issued Janatha Mediclaim Policy to complainant and her family members. During the subsistence of policy the claim was made by the husband of complainant under Ex.A2.  As seen from Ex.A2 claim form, the date of illness/disease/accident is noted as 25-04-09 in column No.6 of the claim form. The date of illness/disease first detected was also noted as 25-04-09 in column No.7 of Ex.A2 and date of admission was noted as 25-03-09 and date of discharge was noted as 05-04-09 in Ex.A2 claim form.  Thus there is discrepancy relating to the month noted in the said columns, for which the learned counsel for complainant stated that it is only by mistake, the month is noted as ‘4’ instead of ‘3’ in column Nos.6 and 7.  Further the room rent was noted as Rs.19,200/- for 12 days and Rs.12,219/- was noted against anesthesia/blood/OT charges/medicines/investigations and the total amount is shown as Rs.31,419/- in Ex.A2.  The case of complainant is that his wife Bhagya Lakshmi was admitted in the hospital on 25-03-09. As seen from Ex.A5 bunch of bills, under receipt No.84 dt.25-03-09 an amount of Rs.25,600/- was received by the hospital towards hospital expenditure. 

                During the course of arguments, the learned counsel for opposite party argued that it is not known as to how the complainant anticipated the total amount of bill payable by the date of discharge as Rs.25,600/- and paid the same under receipt No.84, dt.25-03-09 i.e., on the date of admission itself.  In the said receipt, it was noted as hospital expenditure but not noted as total expenditure by the date of discharge.  Therefore, the doubt expressed by the counsel for opposite party is not tenable.  Further the counsel for opposite party argued that the bill numbers for the bills submitted by complainant are not in serial order for example the bill dt.25-03-09 contains the serial number 159 whereas the bill dt.04-04-09 contains serial number 149 and that therefore the bonafides of bills submitted by complainant are doubtful, for which the learned counsel for complainant replied that the bill numbers may vary since the shop keeper will use one bill book after another and they will not be in continuous serial number and that each bill book contains its own serial numbers.  Therefore, the argument of learned counsel for opposite party relating to the bonafides of bills is untenable. As seen from Ex.A8, complainant made number of representations to the Heritage Health Services Pvt. Ltd. to settle their claim at the earliest.  A perusal of Ex.A9 i.e., letter addressed by opposite party to the Heritage Health Services Pvt. Ltd. dt.19-11-09 reveals that at the request of the insured X-Ray belongs to Bhagya Lakshmi was forwarded in the pending claim and also requested Heritage Health Services Pvt. Ltd. to settle the claim at the earliest. Thus it reveals the claim is pending for want of X-Ray and the said X-Ray was forwarded by opposite party to Heritage Health Services Pvt. Ltd. and requested them to settle the claim at the earliest.  But as seen from Ex.A15 dt.15-12-09, the letter addressed by Heritage Health Services Pvt. Ltd. to the complainant, it was informed to the complainant that the claim submitted by complainant was found inadmissible as per the terms and conditions of policy and the reasons for repudiation are noted as non disclosure of material information.  Ex.A10 does not reveal what is the material information that was not supplied.  Further in Ex.A10 it is noted against remarks as “due to inadequate material information, hence cannot be paid”  and they have further informed to complainant that he has right to appeal against the above rejection to opposite party whose decision in this regard will be final and binding.  It was not specified in Ex.A10 as to what is the material information that was not supplied by the complainant.  Further it was informed that the complainant has right to appeal against the rejection to the opposite party and the decision of opposite party will be final and binding.  In this case, Heritage Health Services Pvt. Ltd., who issued Ex.A10 letter repudiating/rejecting the claim, is not a party to the policy.  The policy was issued by opposite party to the complainant and his family.  The opposite party has neither repudiated nor settled the claim.  We are not able to understand, in what capacity the Heritage Health Services Pvt. Ltd. has repudiated the claim of complainant and its competence thereto. Ex.A2 claim form was submitted by the husband of complainant along with a covering letter dt.10-04-09 to Heritage Health Services Pvt. Ltd.  The said Heritage Health Services Pvt. Ltd. is only a processing agent of opposite party relating to the claims made against opposite party.  Therefore, the claims that were processed by the Heritage Health Services Pvt. Ltd. shall be settled by the opposite party. As already stated above even though the claim was made by the husband of complainant on 10-04-09, the same was not settled or repudiated by opposite party till now.  Subsequent to Ex.A10 dt.15-12-09 letter, the husband of complainant addressed letter         dt.06-01-10 and 11-03-10 to Heritage Health Services Pvt. Ltd. narrating the previous events and requested the Heritage Health Services Pvt. Ltd. to consider their claim at the earliest and the copies of said letters were also marked to opposite party.  The said letters were addressed to Heritage Health Services Pvt. Ltd. by registered post with acknowledgement due marking copies thereof to opposite party.  But inspite of the same the opposite party has not given any reply to the complainant or her husband.  Even though the husband of complainant marked copies of letters requesting to consider the claim subsequent to the repudiation made by the Heritage Health Services Pvt. Ltd., opposite party has not given any reply or settled the claim or confirmed the repudiation of claim made by Heritage Health Services Pvt. Ltd.  In view of the facts and circumstances of case and for the reasons mentioned above, we find deficiency of service on the part of opposite party.  Accordingly this issue is answered in favour of complainant.

POINT No.2

                Since the claim of complainant was neither settled nor repudiated by opposite party we feel that it is just and necessary to direct the opposite party to pay compensation of Rs.1000/- and Rs.500/- towards costs to the complainant and to process claim of complainant at the earliest.  Accordingly this issue is answered.

                In the result, the complaint is allowed in part in terms as indicated below:

  1. The complainant is hereby directed to submit the post operation X-Ray as required by opposite party.
  2. On furnishing post operation X-Ray, the opposite party is hereby directed to settle the claim of complainant in question within a month.
  3. The opposite party is further directed to pay an amount of Rs.1000/- towards compensation and mental agony suffered by complainant.
  4. The opposite party is further directed to pay an amount of Rs.500/- towards costs to the complainant.
  5. The above orders shall be complied within a period of six weeks from the date of receipt of copy of this order, failing which the amounts ordered in item Nos.3 and 4 shall carry interest @ 9% p.a. till the date of realization.  

 

Typed to my dictation by the Junior Steno, corrected by us and pronounced in the open Forum, this the 19th day of May, 2011.

   

 

 

          MEMBER                               MEMBER                            PRESIDENT

 

 

APPENDIX OF EVIDENCE

                                        DOCUMENTS MARKED

For Complainant:

Ex.Nos.

DATE

DESCRIPTION OF DOCUMENTS

 

A1

-

Copy of policy

A2

-

Copy of claim form

A3

05-04-09

Copy of discharge summary

A4

-

Copy of medical certificate showing details of expenditure issued by Dr.K.Sambasiva Rao, Amrutha Nursing Home, Tenali

A5

-

Copies of medical bills (15 in number)

A6

-

Postal receipts (5 in number) and courier receipts (2 in number)   

A7

-

Postal acknowledgements (5 in number)

A8

-

Copies of representations of husband of complainant to Heritage Health Services Pvt. Ltd. on different dates

(7 in number)               

A9

19-11-09

Copy of letter by opposite party to Heritage Health Services Pvt. Ltd.

A10

-

Copies of letters addressed by Heritage Health Services Pvt. Ltd. to the husband of complainant (3 in number)

For Opposite Party:      NIL                                                               

                                                                                               

                                                                                                                                                                                                            

                                                                                              Sd/-XXXX

                                                                                                PRESIDENT

 

 

 

 
 
[HON'BLE MR. A Hazarath Rao]
PRESIDENT
 
[HON'BLE MS. SMT T. SUNEETHA, M.S.W., B.L.,]
MEMBER
 
[HONORABLE Sri M.V.L. Radha Krishna Murthy]
Member

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