United India Insurance Company Ltd.,

    Rep. by its Managing Director,

    Divisional Officer-6, A-501, Ganesh Plaza,

    Opp. Navarangapura Bus Stand,

    Ahmedabad – 380 009.                                    …opposite parties

              This complaint coming up before us for hearing on                      08-07-11 in the presence of Sri A.Varada Raju, advocate for complainant, OP1 set exparte, Sri K.Srinivasa Rao, advocate for OP2, 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 direct the opposite parties to pay an amount of Rs.1,00,000/- being the amount of insurance policy, to pay an amount of Rs.50,000/- towards compensation and to pay Rs.5000/- towards costs. 

The averments of complaint in brief are as follows:

                The complainant joined as a member and obtained membership in 2003 in 1^st opposite party company and renewed the same till 2010.  The complainant also availed 30% discount on regular premium by obtaining mediclaim policy of 2^nd opposite party from the beginning of her membership till 2010. The complainant paid Rs.5885/- in the year 2009 for mediclim policy and obtained group mediclaim policy for the period from 31-03-09 to 30-03-10 under certificate dt.31-03-09 and sum insured is Rs.2,00,000/-.  For that opposite parties have issued mediclaim certificate bearing No.3941 and type of policy is a renewal policy.  On 17-07-09, complainant joined in Usha Mullapudi Cardiac Center due to heart pain and on the same day operation was conducted by placing stent. For that operation she incurred Rs.1,84,981/- towards medical expenses and she was discharged on 22-07-09. After discharge from the hospital, complainant submitted claim form in the 1^st opposite party office on 28-07-09 along with (1) policy copy (2) discharge card / summary (3) final hospital bill (4) specialists bill receipts and certificate (5) certificate for attending medical (6) surgeon that the patients are fully cured and (7) hospital payment receipts for medicalim amount of Rs.1,84,981/-. The opposite parties repudiated the claim on the ground that it related to hypothyroidism and it is pre-existing disease and that all claim documents are not submitted within 15 days from the date of discharge.  The opposite parties issued present policy as a continuous one and renewed previous policy.  The opposite parties are aware that the complainant was taking mediclaim policy since 2003 and they are collecting huge premium every year since 2003.  The opposite parties are taking false and untenable allegations for repudiating the claim.  The opposite parties have arbitrarily repudiated the claim of complainant and it amounts to deficiency of service.  The complainant suffered a loss of Rs.1,84,981/- in addition to mental agony.  Hence, the complaint.

The 1^st opposite party filed its written statement, which is in brief as follows:

                The 1^st opposite party has nothing to do with the settlement of claims or processing thereof.  The 1^st opposite party only deposits the insurance premium in favour of its members. The responsibility and liability of 1^st opposite party remains seized as soon as it deposits the premium to 2^nd opposite party.  The complaint is confined to 2^nd opposite party who decides the claim in accordance with the terms and conditions of policy.  Hence, the complaint against 1^st opposite party may be dismissed with costs.

The 2^nd opposite party filed its version, which is in brief as follows:

                Most of the allegations made in the complaint are false, incorrect and misleading and the complaint is put to strict proof of the same.  The complaint is not maintainable either at law or on facts.  The complainant approached the 3^rd party administrator MD India Health Services (TPA) Pvt. Ltd. through hospital authorities i.e., Usha Mullapudi Cardiac Center, Hyderabad for cashless hospitalization on 17-07-09, which was denied as eligibility of claim under the policy cannot be ascertained.  The liability of 2^nd opposite party is subject to terms and conditions of policy.  As could be seen from the records of TPA our penal of doctors have securitized the claim documents submitted by complainant and made following observations:

1. Policy coverage of M.Satyavathi is for 6 years
2. Inception date of policy is 31-03-03
3. Current policy is in 7^th year    
4. As per claim documents and DAL docket it is observed that patient is known case of hypothyroidism since 8 years, current claim is related to hypothyroidism.  Hence, it is preexisting disease.  All claim documents not submitted within 15 days form the date of discharge.       
5. As per clause Nos.4.1 and 5.4 of terms and conditions of policy claim is not payable.

                Basing on the above remarks the 3^rd party administrator of 2^nd opposite party repudiated the claim on 17-08-09 as such there is no deficiency of service on the part of 2^nd opposite party.  Hence, the complaint may be dismissed.

                The complainant and 2^nd opposite party have filed their respective affidavits in support of their allegations.  The 1^st opposite party remained exparte.

                On behalf of complainant Ex.A1 to A6 are marked and on behalf of 2^nd opposite party Ex.B1 to B9 are marked.

Now the points for consideration are

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

POINT No.1

                The case of the complainant is that she joined as a member of 1^st opposite party in 2003 and renewed the same till 2010 that she paid Rs.5885/- in the year 2009 for mediclaim policy and obtained policy for the period from 31-03-03 to 30-03-10 from 2^nd opposite party, that on 17-07-09 she joined in Usha Mullapudi Cardiac Center due to heart pain and on the same day operation was conducted by placing a stent, for that operation she incurred Rs.1,84,981/- towards medical expenses, that she made a claim with the required documents and that 2^nd opposite party repudiated her claim on the ground of pre-existing disease and that the said repudiation is arbitrary and that there is deficiency of service on the part of opposite parties in settling the claim.

                The case of 1^st opposite party is that it has nothing to do with the settlement of claim and that it is only corporate agent of 2^nd opposite party and that there is no deficiency of service on its part.

                The case of 2^nd opposite party is that the panel of doctors scrutinized the claim documents submitted by complainant and observed that the patient is known case of hypothyroidism since 8 years, current claim is related to hypothyroidism hence, it is pre-existing disease and that as per clause No.4.1 of the terms and conditions of policy claim is not payable and that the third party administrator repudiated the claim and the same was informed to the complainant.  Hence, there is no deficiency of service on their part.

                As seen from Ex.A1 copy of policy, the period of policy is from 31-03-09 to 30-03-10 and that the sum assured for the complainant is Rs.1,00,000/-.  The complainant made claim under Ex.A2 for the medical expenses incurred by her.  The complainant was admitted in the Usha Mullapudi Cardiac Center on 17-07-09 and she was discharged on 22-07-09 as evidenced under Ex.A4.  As seen from Ex.A4, the diagnosis as noted hereunder:

• HYPOTHYROIDISM
• ISCHEMIC HEART DISEASE

                   CHORNIC STABLE ANGINA

                   NORMAL LV FUNCTION

• POST PTCA STATUS:

    SUCCESSFUL PTCA WITH STENT TO LCX (2.5 X 18 mm Xience V)

                The claim of the complainant was repudiated and the same was informed to the complainant under Ex.B2. The grounds of repudiation as noted in Ex.B2 are given hereunder:

                “1. Policy coverage for M.Satyavathi is for 6 year/years. 2 Inception date of policy is 31-Mar-2003. 3 Current policy is in Seventh year/years. 4 Current illness is since as per 5 current illness is a complication of which is since as per 6 As per claim documents & DAL docket it is observed that patient is known case of hypothyroidism since 8 years, current claim is related to Hypothyroidism hence it is pre-existing disease.  Also all claim documents not submitted within 15 days from date of discharge. 7 As per policy terms and conditions, claim is not payable, under Clause 5.4/4.1”  

                Even though it was mentioned in Ex.A4 as chronic stable angina, it was not noted as to how long the disease was persisting. As evident from Ex.A1, during the subsistence of policy, the complainant was admitted in the hospital on 17-07-09 and discharged on 22-07-09 and that she incurred an expenditure of Rs.1,84,981/- towards her treatment vide Ex.A6.  No evidence is placed by 2^nd opposite party in support of the grounds of repudiation made under Ex.B2.  Even though it was mentioned in the repudiation that the patient is known case of hypothyroidism since 8 years and that it is pre-existing disease, no evidence is placed by 2^nd opposite party to that extent.  Further there is no evidence on record to show that the complainant has got knowledge about the said disease.  Therefore, in the absence of any evidence in support of repudiation made by 2^nd opposite party, it can be safely concluded that the complainant is entitled for the medical expenses incurred by her and 2^nd opposite party is liable to pay the same as per Ex.B1 policy and B9 mediclaim certificate. The 1^st opposite party is only a corporate agent of 2^nd opposite party and that 1^st opposite party has noting to do with the settlement of claim.  Therefore, 1^st opposite party is not liable for the claim made by complainant. Accordingly this issue is answered in favour of complainant and against the 2^nd opposite party.

POINT No.2

                The complainant claimed insured amount of Rs.1,00,000/- besides compensation of Rs.50,000/- and expenses of Rs.5000/-. As seen from Ex.A1, the sum assured is only Rs.1,00,000/-  As seen from Ex.B9 mediclaim certificate for a major surgery – angio plasty, the policy holder i.e., the insured is entitled to claim 70% of the sum assured subject to a maximum of Rs.2,00,000/-.  Since the assured amount is only Rs.1,00,000/-, the complainant is only entitled for 70% of the assured amount i.e., Rs.70,000/- towards the medical expenses incurred by her. The amounts claimed towards compensation and costs are too high and they are imaginary.  Therefore, we feel that awarding compensation of Rs.5000/- and Rs.1000/- towards costs will meet the ends of justice. Accordingly this issue is answered in favour of the complainant and against 2^nd opposite party.

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

1. The 2^nd opposite party is hereby directed to pay an amount of Rs.70,000/- to the complainant towards medical expenses  incurred by her together with interest at 9% p.a. thereon from the date of repudiation i.e., 17-08-09 till the date of payment.
2. The 2^nd opposite party is further directed to pay an amount of Rs.5000/- towards compensation for the mental agony suffered by the complainant and Rs.1000/- towards legal expenses to the complainant. 
3. The amounts ordered above shall be paid within a period of six weeks from the date of receipt of copy of this order, failing which, the amounts ordered in item No.2 shall also carry interest at 9% p.a. till the date of realization.        

Typed to my dictation by the Junior Stenographer, corrected by me and pronounced in the open Forum, this the 21^st day of July 2011.

MEMBER                               MEMBER                            PRESIDENT
APPENDIX OF EVIDENCE

                                        DOCUMENTS MARKED

For Complainant:

For 2^nd opposite party:

                                                                                                                                                                             PRESIDENT