BEFORE THE DISTRICT FORUM:KURNOOL
Present: Sri.K.V.H. Prasad, B.A., LL.B President
And
Smt. C.Preethi, M.A.LL.B., Lady Member
Friday the 12th day of December, 2008
C.C.No. 90/08
Between:
G. Uma Maheswara Rao, S/o. G.Seeta Rama Rao,
R/o. D.No.45/142/2-A, Plot No.55, Ramalingeswara Nagar, Sri. Venkataramana Colony, Kurnool. … Complainant
Versus
United India Insurance Company Limited, Represented by its Divisional Manager,
Kurnool. … Opposite party
This complaint is coming on this day for orders in the presence of Sri. M. L Sreenivasa Reddy, Advocate, for the complainant, and Sri. K. Muralidhar , Advocate, for the opposite party and upon perusing the material papers on record, the Forum made the following.
ORDER
(As per Sri. K.V.H.Prasad, President)
C.C.No.90/08
1. This case of the complainant is filed U/S 12 of C.P.Act seeking direction on the opposite party to pay to the complainant Rs.16, 266/- towards incurred medical expenditure along with interest from 27-6-2007 , Rs.10,000/- as compensation for mental agony and cost of the case alleging the deficiency of service on the part of the opposite party in settlement of bill of Rs.16,266/- submitted for medical reimbursement under medi claim policy offering only Rs. 13,058/- alleging several alterrations in medical prescriptions and bills submitted and the opposite party not even paying the said amount inspite of submission of discharge voucher for Rs.13,058/-and giving evasive reply to the complainants notice dated 16-3-2007.
2. In pursuance of the receipt of the notice of this forum as to this case of the complainant the opposite party caused its appearance through its counsel and contested the case filling written version denying any of its deficiency liability for complainants claim.
- The written version of the opposite party besides questioning the justness and maintainability of the complainants case and requiring the strict proof of complaint averments allege no cause of action for the case of the complainant as there being any repudiation of claim being it still in process for want of certain clarifications sought from the complainant as to corrections and proper representation of bills supported by prescriptions and as to unattested alterations and the settlement of claim for Rs. 13,058/- is with transparent reasons and in due compliance of the conditionalities , norms and procedures meant for processing and settling the claims which is know of the complainant as ex-officer of the opposite party dealing in claims and this endeavour of the complainant is to coerce the opposite party to its terms and conditions under the threat of vexatious litigation and so the case of the complainant being devoid of proper cause of action and being in abuse of the process of law seeks dismissal of the complaint with exemplary cost in favour of the opposite party.
- In substantiation of the contentions while the complainant side has taken reliance on documentary record in Ex.A1 to A18 and his sworn affidavit , the opposite party side has taken reliance on documentary record in E.xB1 to B11 and its sworn affidavit .
- Hence the point for consideration is whether the complainant has made out any deficiencies of the opposite party in settlement of his medical claim and there by any liability of the opposite party to the complainants claim.
- The Ex.B2 is a medical prescription said to have been issued to the complainant by one doctor A. Abraham Lincoln . There appears an overwriting at the date which makes it to show as 12 . It consists of five medicines for prescriptions to the complainant . The E.xB3 bill dated 12-6-2006 shows the purchase of three medicines only among them for an amount of Rs.123/- .Even though there is a correction as to the cost of the second medicine mentioned therein but it does not appear to be vital as agreeing to the total amount paid and there by provides any material to doubt the genuineness of said correction in Ex.B3 . Hence there appears any validity in the act of the opposite party rejecting the amount of Rs.123/- envisaged in Ex.B3 . In the same way the over writing in Ex.B2 as to date needs to be taken any serious note of especially when it was followed with the purchase of some medicines mentioned there in especially when the opposite party did not bother to ascertain as to any molafidees in said corrections enquiring with the persons having privy to those documents during its enquiry .
- The Ex.B4 , B8 and B9 are cash memos for purchase of medicines worth Rs.520/- , Rs. 298/- and Rs.321 /- by the complainant on alleged prescriptions of doctor Abraham Lincoln and Dr. Ravindranath . There appears a correction as to the date of the bill in Ex.B4 . The said correction was neither appended by its issuer nor any prescription covering it is placed for appreciation . Any medicines prescriptions in support of the bills in Ex.B8 and B9 are even placed for appreciation to feel the said medicines were purchased for meeting any ailment of the complainant . A mere purchase of medicines by complainant without any prescription contemplates its mere purchase and not for use by the complainant for any ailment and so the opposite party is remaining justified in rejecting the said bill amounts from the claim of the complainant .
- As the prescription in Ex.B5 dated 12-6-2006 being a second one to Ex.B2 without any explanation for its necessity on the very same day of Ex.B2 and not followed with any purchase of medicines indicated in said Ex.B5 and such a mere prescription does not infer its use by the complainant expending any amount , and so the opposite party is remaining justified in rejecting the said E.xB5 from taking into consideration in the claim of the complainant .
- The Ex.B6 is prescription of Gowri Gopal Hospital said to have been issued to the complainant . There is an un attested correction as to the date in it. The medicines prescriptions there in finds a purchase by the complainant in E.xB7 cash bill dated 14-6-2006 . Hence the said correction as to the date needs for any consideration with doubt especially when the opposite party never bothered for ascertaining of any malafidees in the said correction as to date in Ex.B6 during its enquiry with the persons having privy to it . Consequently, the opposite party is not remaining justified in rejecting the amount of Rs.49.50 envisaged in Ex.B7 from the claim amount of the complainant .
- The Ex.B10 and B11 are receipts dated 14-6-2006 and 24-6-2006 alleged to have been issued Chinna Clinical Laboratory , Kurnool in favour of the complainant for an amount of Rs.200/- and Rs.120/- as lab charges for 2-6-2006 and 12-6-2006 and blood sugar test done on 26-6-2006 and for random and fasting test done on 23-6-2006 . But there being any corresponding prescriptions for having said test by the complainant there appears any justifiability in said claim and so the opposite party is remaining justified in rejecting the amounts under Ex.B10 and B11 from the claim of the complainant .
- The Ex.A1 , A5 ,A6 , A8 , A10, A11, A12, A13 ,A15and A16 marked on complainant side merely being correspondence of the complainant with the opposite party and the E.xA7 , A9 , A12 , A14 , A17and 18 being responses of the opposite party to the complainant they reflect any cogent material justifying the claim of the complainant as he contents .
- In the light of the above discussion the amount of Rs.13,058/- alleging to have been allowed by the opposite party as is not including the amounts held entitled to the complainant under Ex.B3 and B7 the entitleness of the complainant works out to Rs.13,230.50 ( ie., Rs.13,058 + Rs.123 + Rs.49.50 ) at the liability of the opposite party under said medi claim policy.
- As the amount said to have been settled by the opposite party to the entitleness of the complainant being not of much considerable variance there appears any justification in claim of Rs.10,000/- towards mental agony and so the said claim is rejected.
- As the opposite party by not entertaining the admissible claim under Ex.B3 and B7 driven the complainant to the forum for justifiable redressal the opposite party holds liability to pay to the complainant an amount of Rs.500/- as cost of the case.
- Consequently, the case of the complainant is allowed accordingly directing the opposite party to pay to the complainant Rs.13,231/- , making the entitled amount of Rs.13,230.50 to its nearest rupee , towards the medi claim of the incurred expenditure of the complainant , and Rs.500/- as cost of the case within a month of receipt of this order. In default the opposite party shall be liable to pay the supra stated award amount to the complainant with 12% interest from the date of default till realization .
Dictated to the stenographer, transcribed by her, corrected and pronounced by us in the open bench on this the 12th day of December, 2008.
Sd/- Sd/-
MEMBER PRESIDENT
APPENDIX OF EVIDENCE
Witnesses Examined
For the complainant :Nil For the opposite parties :Nil
List of exhibits marked for the complainant:-
Ex.A1. Letter dated 14-6-2006 of Complainant to OP.
Ex.A2. Carbon copy of detail of incurred expenditure from
12-6-2006 to 21-6-2006.
Ex.A3. In patient bill statement issued by Gouri Gopal Hospital.
Ex.A4. Discharge card
Ex.A5. Covering letter dated 26-7-2006 by complainant to OP
As to enclosure medical bills and lab bills for the period
21-6-2006 to 10-7-2006.
Ex.A6. Carbon copy of letter dated 18-10-2006 of complainant to OP.
EX.A7. Reply of OP dated nil to Ex.A6.
Ex.A8. Office letter 17-11-2006 of complainant to OP.
Ex.A9. Reply of OP dated 4-12-2006 to Ex.A8
Ex.A10. Reply of complainant dated 25-12-2006 to Ex.A9.
Ex.A11. Office copy of legal notice dated 16-03-2007.
Ex.A12. Reply dated 7-4-2007 to OP to Ex.A 11.
Ex.A13. Letter dated 30-05-2007 of complainant to OP.
Ex.A14. Letter dated 18-6-2007 of OP to complainant along with
Claim disbursement voucher.
Ex.A15. Letter dated 21-06-2007 of complainant to OP.
Ex.A16. Letter dated 9-8-2007 of complaint to OP.
Ex.A17. Letter dated 31-07-2007 of OP to complainant along with
Claim disbursement voucher.
Ex.A18. Letter dated 20-08-2007 of OP to complainant along with
Claim disbursement voucher.
List of exhibits marked for the opposite parties:
Ex.B1. Original in patient bill statement dated 21-6-2006.
Ex.B2. Prescription dated 12-6-2006.
Ex.B3. Medical bill dated 12-6-2006.
Ex.B4. Medical bill dated 13-6-2006.
Ex.B5. Prescription dated 12-6-2006.
Ex.B6. Prescription dated 14-06-2006.
Ex.B7. Medical bill dated 14-06-2006.
Ex.B8. Medical bill dated 30-06-2006.
Ex.B9. Medical bill dated 10-07-2006.
Ex.B10. Receipt dated 14-06-2006 for Rs.200/-.
Ex.B11. Receipt dated 24-06-2006.
Sd/- Sd/-
MEMBER PRESIDENT
// Certified free copy communicated under Rule 4 (10) of the
A.P.S.C.D.R.C. Rules, 1987//
Copy to:-
Complainant and Opposite parties
Copy was made ready on :
Copy was dispatched on
