Per Sri A. Hazarath Rao,  President:-

The complainant filed this complaint u/s 12 of the Consumer Protection Act, seeking reimbursement of Rs.2,35,000/- incurred towards medical expenses; Rs.50,000/- towards mental agony and Rs.10,000/- towards costs.

2.  In brief the averments of the complaint are these:

        The complainant is having account with the 2^nd opposite party and the said account was linked with Arogyadan mediclaim insurance policy of the 1^st opposite party.   The 1^st opposite party issued policy bearing No.050400/48/10/4100000193 with GHPL-EAV-ARG-48-199/2 branch code.242.   The complainant paid necessary premium to cover risk of himself, his wife and his son.   The complainant is a policy holder of the said policy since five years.   The said policy covered the period from 30-03-11 to  29-03-12.   The complainant on 18-05-11 underwent CABG surgery in M/s Global hospitals, Hyderabad.   Before undergoing surgery the complainant sent all details to the 3^rd opposite party which is an administrator requesting cashless facility.   The 3^rd opposite party refused to accord cashless facility to the complainant alleging pre-existing disease.  The complainant somehow or other incurred Rs.2,35,000/- for the CABG surgery besides incurring other expenses.   The complainant took treatment as in patient in the said hospital during 18-05-11 – 29-05-11.   The complainant again got admitted on 04-06-11 due to emergency condition.   The complainant submitted a claim to the 3^rd opposite party for reimbursement of expenses incurred towards surgery, hospitalization and treatment.   On enquiry the complainant came to know through 2^nd opposite party that his claim was repudiated on certain flimsy grounds.   Neither the 1^st opposite party nor the 3^rd opposite party communicated the said repudiation to the complainant. The reasons mentioned in the repudiation letter sent to the 2^nd opposite party are not correct.   The complainant was hale and healthy prior to undergoing CABG.   The alleged pre-existing disease is not within three years from the inception of the policy.   Doctors identified the ailment on 11-05-05 only.   The complainant did not suffer from hyper tension previously and it is not a factor for CAD-TVD.   The 1^st opposite party did not give reply to the notice dated 04-04-02 got issued by the complainant.   The repudiation of claim by the 1^st opposite party on flimsy grounds amounted to deficiency of service.   The complainant was put to huge financial loss besides mental agony and estimated the same at Rs.50,000/-.   The complaint therefore be allowed.

3.  The opposite parties 2 and 3 remained exparte.

4.   The contention of the 1^st opposite party in nutshell is hereunder:

        The complainant is having an account with the 2^nd opposite party.   The 1^st opposite party have issued group mediclaim insurance for account holders of the 2^nd opposite party.  The complainant was covered by the policy bearing No.0504000/48/10/41/0000193 and the said policy covered the period from 30-03-11 to 29-03-12 for Rs.1,00,000/-.   The 1^st opposite party informed repudiation of the claim to the complainant by its letter dated 05-08-11.  The complainant’s contention about his policy being continuous one is not correct.   The policy in question was renewed with effect from 30-03-11 which ought to have been renewed on or before 23-03-01 to have the continuity and renewal benefits.   The treatment was given for coronary artery disease and triple vessel disease and it becomes pre existing disease with the person policy.  Thus the opposite party repudiated its claim as per terms and conditions of the policy.   The complainant did not approach the Forum with clean hands.   The 1^st opposite party did not commit any deficiency of service.  The complaint therefore be dismissed.    

5.   Exs.A-1 to A-48 on behalf of complainant and Exs.B-1 to B-3 on behalf of 1^st opposite party were marked.

6.  Now the points that arose for consideration are:     

1. Whether the repudiation of claim by the 1^st opposite party is not justifiable and if so amounted to deficiency of service?
2. Whether the complainant is entitled to compensation?
3. To what relief?

7.   POINT No.1:-   Ex.A-1 is the copy of certificate of insurance issued by the opposite party in favour of the complainant covering the period from 05-06-06 to 05-07-07.   Ex.A-2 is the copy of certificate of insurance issued by the 1^st opposite party in favour of the complainant covering the period from 18-07-08 to 17-07-09.  Ex.A-3 is copy of certificate of insurance issued by the 1^st opposite party in favour of the complainant covering the period from 09-03-10 to 08-03-11 and it corresponds to Ex.A-4 proposal form.   Ex.A-7 is the copy of certificate of insurance issued by the 1^st opposite party in favour of Smt Y. Bhanu Bhavani wife of the complainant covering the period from 30-03-11 to 29-03-12 and it corresponds to Ex.A-5 proposal form.  The details of Exs.A-1 to A-3 and A-7 were mentioned in Ex.B-3.

8.     The 1^st opposite party refusing to extend cashless facility on the ground of pre existing disease was not in dispute (Ex.A-8).   The certificates of insurance for the period from 06-07-06 to 05-07-07 (Ex.A-1); for the period from 18-07-08 to 17-07-09 (Ex.A-2); for the period from 09-03-10 to 08-03-11 (Ex.A-3) were in the name of Gorijala Karuna Ramana i.e., the complainant while the certificate of insurance for the period from 30-03-11 to 29-03-12 was in the name of Smt Y. Bhanu Bhavani i.e, wife of the complainant.   Ex.A-4 is the corresponding proposal form for Ex.A-3 certificate of insurance.  In Ex.A-4 proposal form name of the proposer was shown as Y. Bhanu Bhavani.  But the certificate of insurance was given in the name of Gorijala Karuna Ramana.  Likewise Ex.A-5 proposal form corresponds to Ex.A-7 certificate of insurance.   In Ex.A-5 proposal form name of the proposer was shown as Gorijala Karuna Ramana.  But Ex.A-7 certificate of insurance was in the name of Y. Bhanu Bhavani.   Under all the insurance policies the family members covered were one and the same.   It is for the opposite party to explain how they issued certificate of insurance in the name of person other than the proposer which it did not explain.  

9.     Ex.B-2 agreement was in between the opposite parties 1 and 2.  Terms of the said agreement cannot be known to insured like complainant.  Separate certificate of insurances were given to individual account holders like complainant even though Ex.B-2 was in between the opposite parties 1 and 2.  In Ex.A-7 (corresponding to Ex.A-5 proposal form) only the words “If renewed within 15 days from renewal date continuation of policy is given but any claim during the break period will not be entertained”.   Those words will amount to a caution to any proposer who in turn can follow.  Such words did not find place in Exs.A-1 to A-3 i.e., earlier policies.     Nowhere in Exs.A-1 to A-3 and A-7 it was mentioned that the insurer have supplied terms of Ex.B-2 and salient features of the AB Arogyadan mediclaim policy (Ex.B-1) and if supplied the complainant ought to have known them.  Under those circumstances, absence of above caution in my considered opinion is a material lapse and amounted to deficiency of service. 

10.   The complainant contended that the 1^st opposite party or                    3^rd opposite party did not communicate repudiation of claim to him and he came to know it through the 2^nd opposite party.  Ex.A-13 repudiation claim was addressed to Smt Y. Bhanu Bhavani i.e., wife of the complainant marking a copy to M/s Andhra Bank, head office, Hyderabad.  Therefore the contention of the complainant that it came to know the repudiation through 2^nd opposite party cannot be believed.   Such a mis-statement did not entitle the complainant for the relief if otherwise entitled to. 

11.   The complainant is not aware of the insured amount as rightly contended by the contesting opposite party. Therefore the complainant is entitled to the insured amount in our considered opinion.   For the discussion made supra, we answer this point in favour of the complainant.  

12.  POINT No.2:-    The complainant claimed Rs.50,000/- towards mental agony.   We already observed that complainant is not aware of the insured amount.   The complainant gave an opportunity for the opposite party to repudiate the claim since he has not claimed properly.  Under those circumstances awarding damages in our considered opinion is not proper.   We therefore answer this point against the complainant.

13.  POINT No.3:-    In view of above findings, in the result the complaint is allowed partly as indicated below:

1. The 1^st opposite party is directed to pay Rs.1,00,000/- (Rupees one lakh only) together with interest @9% pa.., from 05-08-11 till payment.
2. The 1^st opposite party is directed to pay Rs.1,000/- (Rupees one thousand only) to the complainant towards costs.   
3. The relief against the opposite parties 2 and 3 is dismissed.
4. The amounts ordered above shall be paid within a period of six weeks from the date of receipt of the copy of the order.

              Typed to my dictation by Junior Stenographer, corrected by me and pronounced in the open Forum dated this the 17^th of January, 2013.

          MEMBER                                                            PRESIDENT

APPENDIX OF EVIDENCE

DOCUMENTS MARKED

For Complainant  :

For Opposite Party  :

                                                                                                                                                                               PRESIDENT