BEFORE THE DISTRICT FORUM:: WEST GODAVARI:: ELURU
Sri. P. SRIDHARA RAO, B.Sc., L.L.B.,
Sri. B. Apparao, M.A., M.L.,
Thursday, the 30th day of April, 2009
CONSUMER COMPLAINT NO. 107/2008
Mareedu Srihari Rao, S/o Naganna, Tirumalapuram village
Jangareddigudem, W.G. Dist., -- Complainant
1. The Chief Executive, Family Health Planning Ltd.,
AdityaTowers, 3,4, Floor, Road No.2
Banjara Hills, Hyderabad .34
2. The Manager
Andhra Bank, Bhayyannagudem village,
Koyyalagudem Mandal, W.G. Dist.,
3. United India Insurance Co., Ltd.,
Hyderabad. -- Opposite Party
This complaint coming before us for final hearing on 15-4-2009 and on perusing the Complaint, versions and other material papers on record and on hearing the arguments of the complainant appeared in person and Sri. Ch. Bheemeswara Rao, Advocate for the 1st opposite party, K. Kasturi, Advocate for the 2nd opposite party and Sri. D. Satyanarayana, Advocate for the 3rd opposite party and the matter having stood over for consideration to this day, this forum made the following:-
The complainant filed the present complaint under Sec. 12 (B) of Consumer Protection Act with a prayer to direct the opposite parties 1 to 3 to pay a sum of Rs.50,000/- towards service and further sum of Rs.50,000/- towards interest and costs. The averments of the complainant in brief are that :
2. The complainant is an agriculturist having S.B.A/c No. ABJ173 in Andhra Bank, Bhayyannagudem branch/2nd opposite party. On 8-6-2005 the Andhra Bank, Bhayyannagudem Branch deducted a sum of Rs.969/- towards medical insurance under Arogyadhan scheme from the account of the complainant and credited the amount to the family health plan, Hyderaband/1st opposite party. The said health scheme will be in force from 9-6-2005 to 8-6-2006. While the matter stood thus, due to his ill health, the complainant in the month of December, 2005 went and joined in the hospital of Dr. V.Y. Rao at Vijayawada who inturn intimated the said fact to the 1st opposite party on 21-12-2006. it is further alleged that in the meantime, due to some unavoidable circumstances, the complainant underwent surgery pertains to his heath in Usha Mullapudi Cardiac Center, Hyderabad in the month of January, 2006 and lodged claim for a sum of Rs.1,15,293/- basing on the bills issued by the hospital authorities with the 1st opposite party who inturn rejected the claim. Later on the advise of Consumer Counsel of Jangareddigudem Mandal, the complainant got issued notice dt. 30-3-2007 to both the parties demanding payment of the bill amount. But the complainant did not receive any reply regarding settlement of the claim from the opposite parties. Thus the present complaint is filed for the aforesaid reliefs.
3. It is necessary to mention here that during the pendency of the complaint and after filing the version by the 1st opposite party taking a plea that the United India Insurance Co., Ltd., is a proper and necessary party for adjudication of this complaint, the complainant added United India Insurance Co., Ltd., as a 3rd opposite party as per the order in I.A.No.582/2008 dt. 2-9-2008.
4. The 1st opposite party filed his version resisting the complaint and contended that it has received authorization letter from Usha Mullapudi Cardiac Center, Hyderabad stating that the complainant again admitted on 21-12-2005 in the hospital for the treatment of CAD and that the complainant is a “known case of CAD/SVD, Unstable Angina, Normal LV Function EF.69% since 2002 and as such, s per the above said information, the 1st opposite party rejected the authorization vide PA 18194 since the claim was contrary to the terms and conditions of the policy taken by the complainant with the 3rd opposite party and the same was informed to the hospital through their letter dt. 26-12-2005 and due to the absence of privity of contract and lack of true cause of action, the complaint against this 1st opposite party is liable to be dismissed.
5. The 2nd opposite party filed its version resisting the complaint and stated that this opposite party only a facilitator and is not liable to settle any claim that this opposite party has acted promptly without any negligence that the complainant had given a declaration that in case of any claim under the policy, this 2nd opposite party will not undertake any responsibility or will not accept any correspondence and the same has to be pursued with the 3rd opposite party specified TPA only. The complainant also did not submit any documents or claim papers through this opposite party to the 1st opposite party as such this opposite party was not aware of the claim and as such there is no deficiency in service on its part and thus the complaint is liable to be dismissed with costs against this opposite party.
6. The 3rd opposite party filed its version protesting the complaint stated that at the time when the complainant submitted claim application for the reimbursement of the medical expenses of Rs.1,15,293/- paid by him to Usha Cardiac Center, Hyderabad, the 1st opposite party basing on the Angiogram Report given by Usha Cardiac Centre, Vijayawada, has rightly rejected the claim confirming that the complainant is a known case of Caronary Artary Disease presented with Angina and Dyspnoea NYHA GRADE III which does not come under the purview of the policy under Clause 4(2) of Standard General Exclusions of Medi Claim policy. Further the complainant never directly approached this 3rd opposite party and in fact he made all correspondence with the 1st opposite party only that the 1st opposite party as a third party administrator to the 3rd opposite party processed the claim of the complainant promptly and fairly without any hesitation and so there is no deficiency in service on the part of either the 1st opposite party as well as the 3rd opposite party. As such there is no necessity to pay compensation to the complainant in any manner and therefore the complaint is liable to be dismissed with costs against this opposite party.
7. The complainant in proof of his complaint filed his affidavit supporting the averments of his complaint and got marked Ex A.1 to Ex A.13. The opposite parties 1 to 3 filed their affidavits in support of their versions filed by them and got no documents marked.
8. The points for determination now are :
1.Whether the rejection of the claim made by the complainant by the 1st opposite party as a third party administrator of 3rd opposite party is justifiable and whether the complainant is entitled for the reliefs sought for by him ?
2.To what relief ?
POINT No: 1 :
As seen from the material placed on record by both sides, there is no dispute about the complainant having S.B. A/c with the 2nd opposite party and his obtaining of Medical Insurance Policy from the 3rd opposite party through the 2nd opposite party covering the risk for a period commencing from 9-6-2005 to 8-6-2006 and his undergoing treatment for the first time from 21-12-2005 to 24-12-2005 in Usha Mullapudi Cardiac Centre, Vijayawada and for the 2nd time on 26-12-2005 in Usha Mullapudi Cardiac Centre, Hyderabad.
It is the contention of the complainant that for his admission and undergoing surgery to his heart in Usha Mullapudi Cardiac Centre at Hyderabad on 26-12-2005, he incurred a sum of Rs.1,15,293/- towards treatment and as such he is entitled for the reimbursement of entire treatment costs of Rs.1,15,293/-.
It is the contention of the 2nd opposite party that it is only a facilitator and it is not liable to settle any claim and the complainant had given a declaration and undertaking that in case of any claim under the said policy, the 2nd opposite party will not undertake any responsibility or will not accept any correspondence and the same has to be pursued with the 3rd opposite party only and so the 2nd opposite party is not having any responsibility in settling the claim.
The complainant has not disputed the said contention of the 2nd opposite party at anywhere in the material placed on record. Therefore in view of the said situation, the claim against the 2nd opposite party is liable to be dismissed.
The question that has to be seen now is whether the complainant is entitled for the reliefs sought for by him against the opposite parties 1 and 3 ?.
As per the version of the 3rd opposite party and the affidavit filed in support of it, it is a fact that the 1st opposite party is a 3rd party administrator to the 3rd opposite party and processed the claim of the complainant. It is the contention of the complainant that as on the date of his undergoing treatment to his heart disease in Usha Mullapudi Cardiac Centre at Hyderabad, the policy was in force and so he is entitled for the relief sought for by him. On the other hand, the contention of the opposite parties 1 and 3 is that the complainant took the medi-claim policy for an assured sum of Rs.50,000/- for the period covering from 9-6-2005 to 8-6-2006 by suppressing the fact of his suffering from pre-existing disease, as such the 1st opposite party rejected the claim made by the complainant stating that the complainant is suffering from pre-existing disease and the claim does not come under the purview of the policy under Clause 4(2) of Standard General Exclusions of Medi-claim policy, and so the opposite parties 1 and 3 are not liable to reimburse the claim made by the complainant and as such the complaint is liable to be dismissed. So the question that has to be seen now is whether the contention raised by the opposite parties 1 and 3 is tenable ?
It is the contention of the learned counsel for the 3rd opposite party that the complainant submitted the insurance proposal form to the 3rd opposite party showing Dash (-) at relevant column No.9 against the existing disease/illness/injury. The said contention is not disputed by the complainant. Ex A.3 is the copy of Coronary Angiography Report dt. 21-12-2005 issued by Usha Cardiac Centre, Vijayawada. A perusal of the recitals of the said report Ex A.3 clearly goes to show that the complainant was suffering from pre-existing disease since 2002 ie., much earlier to his taking policy which is suppressed by the complainant at the time of his giving proposal form. So as rightly contended to by the learned counsel for the 3rd opposite party, the claim made by the complainant towards reimbursement of expenditure incurred by him for his undergoing treatment to his heart disease in Usha Mullapudi Cardiac Centre, Hyderabad on 26-12-2005 does not come under coverage of the policy in view of Clause 4(2) of Standard General Exclusions of Medi-claim obtained by the complainant in question. Further, admittedly the complainant, to claim the present amount, not even renewed his policy for a period of 3 years continuously without any break under Exclusions (1).
Under the said circumstances and for the reasons stated above, we found that there is some force in the contentions of the learned counsel for the opposite parties. Therefore we hold that the complainant is not entitled for the reliefs sought for by him and thus the complaint is liable to be dismissed.
Point No. 2:
In the result, the complaint is dismissed. No order as to costs.