1
Date of filing:6.3.2013.
Date of disposal:26.8.2013.
BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM - II:
VIJAYAWADA, KRISHNA DISTRICT
Present: SRI A. M. L. NARASIMHA RAO, B.SC., B. L., PRESIDENT
SMT N. TRIPURA SUNDARI, B. COM., B. L., MEMBER.
SRI S.SREERAM, B.COM., B.A., B.L., MEMBER
MONDAY, THE 26th DAY OF AUGUST, 2013
C.C.No.32 of 2013
Between:
Devarapalli Venkata Laxmana Reddy, S/o (Late) Marreddy, Indian, Hindu, 40 years,
Business, R/o D.No.5-48A, A.S.M. College Road, Nunna Post, Vijayawada Rural.
. … Complainant.
AND
1. The United India Insurance Company Ltd., Rep., by it’s Divisional Manager,
Divisional Office, R.R.Appa Rao Street, Vijayawada.
2. T.T.K. Health Care TPA (P) Ltd., Rep., by it’s Manager, 47-14-10, 4th Line, Videesha
Towers, Dwaraka Nagar, Visakhapatnam.
.… Opposite Parties.
This complaint coming on before the Forum for final hearing on 13.8.2013 in thepresence of Sri B,Venkata Reddy, Counsel for complainant and Sri N.V.R.Krishna Kumar, counsel 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 Member Smt N.Tripura Sundari)
The complaint is filed under Section 12 of the Consumer Protection Act, 1986.
1. The averments of the complaint are in brief:
The complainant obtained a medi-claim policy for himself and his wife from the 1st opposite party on 20.4.2010 for a sum of Rs.2,50,000/- and later it was renewed on two occasions. While so during the existence of the policy the wife of the complainant suffered with stomach pain and she approached M/s Andhra Hospital, Vijayawada.
After conducting preliminary tests the said hospital authorities referred the case to M/s Soumya Multio Speciality Hospital, Hyderabad for immediate surgery for LT ovarian cyst. The complainant informed the said fact to the 1st opposite party and the 1st opposite party informed that they would pay all medical bills to the hospital authorities.
Believing the same the complainant joined his wife in M/s Soumya Super Speciality Hospital, Hyderabad on 26.10.2012 and requested the 1st opposite party to arrange payment of medical bills at admission stage. The 1st opposite party advised the complainant to contact the 2nd opposite party. On contacting the 2nd opposite party the 2nd opposite party advised the complainant to spend the amount for medical expenses and later they would reimburse the same. The complainant spent Rs.1,63,263/- towards medical expenses for treatment of his wife and submitted claim form to the opposite parties for the said amount. After keeping the matter for a long time the 2nd opposite party settled the claim only for Rs.50,000/- and refused to settle the balance amount by forwarding a mail. On verification of the said mail the complainant approached the representative of the 2nd opposite party and he advised the complainant to wait that they would refer the claim to their higher officials. The complainant waited upto 29.1.2013 and contacted the 2nd opposite party and was informed that their higher officials were not considered the appeal for resettlement of claim. The opposite parties cheated the complainant by stating that they would reimburse the medical expenses incurred by him. Hence the complainant got issued a legal notice demanding the opposite parties to settle the claim for the expenses incurred by him along with interest and compensation, but the opposite parties failed to do so. Hence the complainant is constrained to file this complaint against the opposite parties praying the Forum to direct the opposite parties to reimburse Rs.1,63,263/- which was incurred by him for recovery of the full claim with interest @ 18% per annum from 26.12.2012 after excluding Rs.50,000/-; to pay damages of Rs.1,00,000/- for causing mental agony and to pay costs.
2. Notices were served to opposite parties 1 and 2 and the `1st opposite party filed its vakalat and version. The 2nd opposite party was called absent.
The version of the 1st opposite party is in brief:
The 1st opposite party denied all the allegations of the complainant and submitted that the cashless facility could not be sanctioned as the hospital had not agreed to be a part of the ‘preferred provider net work’ created by the public sector insurers. This had been informed to the hospital wide letter dated 18.10.2012. When the claim papers were submitted by the insured for the hospitalization undergone, the claim was processed in accordance with the insurance policy in force and the claim was settled for Rs.50,000/- that was the maximum payable for the surgery undergone as per the policy.
As per policy clauses 1.2 wherein it is stated ‘expenses in respect of the following illnesses will be restricted as detailed. Item “c” in the list is “Hysterectomy” against which the policy promises to admit claims to the extent of 20% of the sum insured subject to maximum of Rs.50,000/-. The settlement letter copy which was sent to the complainant, clearly indicates that the amount had been disallowed as it exceed 20% of the sum insured. There is no deficiency in service on the part of opposite parties towards the complainant 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.5 and on behalf of the opposite parties Sri V.Bhushanamma, Assistant Manager of the 1st opposite party gave her affidavit and got marked Ex.B.1.
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 opposite parties towards the complainant in settling the claim of 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 on hand the complainant obtained medi-claim policy for himself and his wife from the 1st opposite party on 20.4.2010 for a sum of Rs.2,50,000/- and later it was renewed on two times under Ex.A.1. The contention of the complainant that during the existence of the policy his wife suffered with stomach pain and she approached M/s Andhra hospital Vijayawada and after preliminary tests her case was referred to M/s Soumya Multi Speciality Hospital, Hyderabad for immediate surgery for LT ovarian cyst. The complainant informed the same to the 1st opposite party and the 1st opposite party assured him to pay the hospital bills. Believing the same he admitted his wife in the said hospital and requested the 1st opposite party to arrange the payment of medical bills at admission stage. The 1st opposite party advised him to contact with the 2nd opposite party and on contacting with the 2nd opposite party he was advised to spend the amount and later they would reimburse the same. The complainant spent Rs.1,63,263/- towards medical expenses for the treatment of his wife and submitted claim form to the opposite parties for the said amount. After a long time the 2nd opposite party settled the claim for Rs.50,000/- under Ex.A.2 and refused to settle the balance amount by forwarding a mail. Hence he got issued a legal notice 31.1.2013 to opposite parties under Ex.A.3. The opposite parties received the said notice under Ex.A.4 and kept quiet.
7. The contention of the opposite parties is that when the claim forms were submitted by the complainant for the amount of hospitalization of his wife, the claim was processed in accordance with the insurance policy in force and the claim was settled for Rs.50,000/- which is maximum payable for the surgery undergone as per policy. As per policy Ex.B.1 clause 1.2 item ‘c’ in the list is “hysterectomy” the policy promises to admit claims to the extent of 20% of the sum insured subject to maximum of Rs.50,000/-. It was clearly mentioned in the settlement letter which was sent to the complainant.
8. On hearing both the parties and on perusing Ex.B.1 family medicare policy, we, the Forum agreed with the submissions of the opposite parties. Therefore we hold that as per policy agreement the complainant is entitled to get only 20% of the sum insured i.e., Rs.50,000/-. The opposite parties rightly settled the claim of the complainant.
Hence we hold that there is no deficiency on the part of opposite parties. The complainant is not entitled for full amount he spent for hospitalization of his wife. These points are answered accordingly.
POINT No.3;-
9. In the result, as the opposite parties expressed their willingness to pay Rs.50,000/- (Fifty thousand rupees only), as per settlement statement this petition is accordingly ordered and the opposite parties are directed to pay Rs.50,000/- (Fifty thousand rupees only) towards claim to the complainant within one month. In the circumstances of the case no order as to costs.
Typewritten by Stenographer K.Sivaram Prasad, corrected by me and pronounced by us in the open Forum, this the 26th day of August, 2013.
PRESIDENT MEMBER MEMBER
APPENDIX OF EVIDENCE WITNESSES EXAMINED
For the complainant: For the opposite parties:-
P.W.1 D.Venkata Laxmana Reddy D.W.1 V.Bhushanamma
Complainant Asst., Manager of the
(by affidavit) 1st opposite party, (by affidavit)
DOCUMENTS MARKED
On behalf of the complainant:-
Ex.A.1 . . Insurance policy.
Ex.A.2 . . Mediclaim computation.
Ex.A.3 31.01.2013 Office copy of legal notice.
Ex.A.4 . . Postal Acknowledgement.
Ex.A.5 31.01.2013 Postal receipt.
For the opposite parties:-
Ex.B.1 . . Photocopy of insurance policy.
PRESIDENT
