Date of filing:23.6.2014.
Date of disposal:31.12.2014.
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
WEDNESDAY, THE 31ST DAY OF DECEMBER, 2014.
C.C.No.143 of 2014
Between:
Koneru Srinivas, S/o Venkata Rao, Hindu, 50 years, Business, R/o Flat No.301, Vasanthagopal Apartment, Thulasinagar, Kanuru, Vijayawada, Krishna District.
.… Complainant.
AND
1. The Oriental Insurance Company Ltd., CBO-4, Vijayawada SBH Complex, Beside Eenadu, Patamata, Vijayawada – 10 Rep., by its Senior Branch Manager, Vijayawada.
2. M/s MD India Health Care Services TPA Pvt., Ltd., MD India House, Survey No.147/8, Sr. Bo, 46/1, Espace, A2, Blg, 4th Floor, Pune Nagar Road, Vadgaonsheri, Pune – 411 014 Rep., by its Manager Pune.
.… Opposite Parties.
This complaint coming on before the Forum for final hearing on 17.12.2014, in the presence of Sri I.Venkateswara Rao, Advocate for complainant and Sri T.Umamaheswara Rao, 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 obtained Happy Family Floater i.e., Health Insurance Policy from the 1st opposite party for himself, his wife and two children. The sum assured under the policy is Rs.3,00,000/. If any of the family members of the complainant effected with ill-health and join as inpatient in the hospital, the 1st opposite party assured to pay Rs.3,00,000/- towards the claim to the hospital authorities through the 2nd opposite party. While so on 3.11.2012 the complainant was admitted into Krishna Institute of Medical Sciences Limited, Vijayawada as he was effected with viral fever. He was discharged from the hospital on 9.11.2012. The complainant incurred an expenditure of Rs.51,471.84 ps towards medical tests, investigations, medicines and consultation charges. The complainant informed the said fact to the opposite parties and requested the opposite parties to settle the claim. The 2nd opposite party paid Rs.25,344.34ps to the hospital authorities and refused to pay the balance amount of Rs.26,127.50ps. As they refused to pay the said amount the complainant was forced to pay the sum to the hospital authorities. Though the opposite parties received premium of Rs.9,910/- per year and assured to reimburse the medical expenses upto Rs.3 lakhs, they failed to do so which amounts to deficiency in service. Hence the complainant is constrained to file this complaint against the opposite parties praying the Forum to direct the opposite parties to pay Rs.50,000/- in all i.e., Rs.26,127.50 towards the bill amount payable to the hospital authorities and Rs.23,872.50ps towards damages along with interest at 24% per annum from the date of discharge of the complainant from the hospital till realization and to pay costs.
2. Notices were served to the opposite parties. The 2nd opposite party remained absent. 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 policy coverage depends on the disease ill-health effected. Though the bills issued to Rs.51.471.84ps towards medical tests, investigations, medicines and consultations with various doctors and for accommodation, ICU charges, it covers subject to terms and conditions and exclusions of the policy. The 2nd opposite party has sent a letter to the concerned hospital how the paid bill was arrived, and informed about declined amount as per the policy schedule. The complainant failed to take into account that 10% of the bill to be borned by the party/insured i.e., Rs.5,111/- servicing charges Rs.15,967.32ps dietician charges Rs.250/- , food and other beverages Rs.28/- and medical record charges Rs.200 are not payable. The total deductions Rs.21,356/- less from the bill amount Rs.51,471.84ps and the amount payable is Rs.25,344.34ps. The opposite parties paid the said amount to the hospital. The complainant has not filed any acknowledgement or letters issued by the KIMS hospital to the opposite parties along with a letter received by the hospital authorities from the 2nd opposite party. The complainant has no sanctity to value the claim to the tune of Rs.50,000/- and it is baseless facts. Therefore there is no deficiency in service on the part of this 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.4. On behalf of the opposite parties Sri K.Ramesh Babu, Divisional Manager filed his affidavit and got marked Ex.B.1 and Ex.B.2
4. Heard and 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 paying the claim amount of the policy 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 material in hand the complainant obtained happy family floater health insurance policy from the 1st opposite party under Ex.A.4 = Ex.B.1 for himself, his wife and two children for an amount of Rs.3,00,000/-. On 3.11.2012 the complainant was admitted into Krishna Institute of Medical Sciences, Vijayawada as he was effected with viral fever and was discharged on 9.11.2012. He incurred an expenditure of Rs.51,471/- towards medical test, investigations, medicines and consultation charges. Ex.A.1 to Ex.A.3 shows the same. He informed the said fact to the opposite parties and requested to settle the claim. The 2nd opposite party paid an amount of Rs.25,344.34ps to the hospital authorities and refused to pay balance amount of Rs.26,127.50ps. As per the opposite parties the complainant is entitled for the claim as per terms and conditions and exclusions of the policy under Ex.B.2 under heads a to e. As per policy terms, the servicing charges payable Rs.15,967.33ps, dietitian charges Rs.250/- food and beverages charges Rs.28/- medical record charges Rs.200/- and 10% of the medical bill i.e., Rs.5,111/- are not payable that amount to be born by the complainant. The deduction amount comes to Rs.21,356/- and it has to be deducted from the total bill amount of Rs.51,471/- and the amount payable comes to Rs.25,344.34ps. Hence the 2nd opposite party paid the said amount of Rs.25,344.34ps to the hospital authorities. In view of Ex.B.2 the terms and conditions of the policy the complainant is entitled only for the amount paid by the opposite parties. Hence there is no deficiency in service on the part of the opposite parties and the complainant is not entitled for any relief as he prayed.
POINT No.3:-
7. In the result, the 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 31st day of December, 2014.
PRESIDENT(FAC) MEMBER
Appendix of evidence
Witnesses examined
For the complainant: For the opposite parties:
P.W.1 Koneru Srinivas D.W.1 K.Ramesh Babu,
Complainant, Divisional Manager
(by affidavit) 1st opposite party (by affidavit)
Documents marked
On behalf of the complainant:
Ex.A.1 . . Photocopies of bunch of receipts.
Ex.A.2 . . Photocopies of bunch of reports.
Ex.A.3 . . photocopy of IP Approximate bill.
Ex.A.4 . . Photocopy of Happy family floater policy schedule.
On behalf of the opposite parties:
Ex.B.1 . . Photocopy of Happy family floater policy schedule.
Ex.B.2 . . Terms and conditions of t he policy.
PRESIDENT(FAC)
