BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM ::

KADAPA Y.S.R DISTRICT

PRESENT SRI V.C. GUNNAIAH, B.Com., M.L., PRESIDENT

                                  SMT. K. SIREESHA, LADY MEMBER

                                  SRI M.V.R. SHARMA, MEMBER

Thursday, 11^th February 2016

CONSUMER COMPLAINT No. 86 / 2015

Gorlamandala Ananda Rao, S/o G. Subbarayudu,

age 55 years, R/a D.No. 13/609,

Y.V. Street, Kadapa.                                                                 ….. Complainant.

Vs.

1.  The Branch Manager, New India Assurance Co. Ltd.,

     D.No. 2/789, 1^st floor, Sairam Towers,

     Nagarajupet, Kadapa City.

2.  The In-charge, Claims Department,

     Good Health Plan Ltd., Plot No. 49, Nagarjuna Hills,

     Panjagutta, Hyderabad – 82.                                             …..  Respondents

This complaint coming on this day for final hearing on 8-02-2016 in the presence of M.D. Ali Khan, Advocate for complainant and Sri A. Rajasekhar, Advocate for R1 and R2 remained absent on 23-11-2015 and upon perusing the material papers on record, the Forum made the following:-

O R D E R

(Per Smt. K. Sireesha, Member),

1.                Complaint filed under section 12  of C.P. Act 1986.

2.                The brief facts of the complaint are as follows:-   The complainant has taken Health Policy for himself and his family members bearing No. 611200/34/07/20/000000154 on 28-6-2007 and maturity period is 17-6-2008 and sum insured is ₹ 2,00,000/- and then the policy was renewed from time to time without any hindrance upto 27-6-2103 the bonus was also accumulated until the date.

3.                     Then the complainant took enhance policy bearing No. 61120034130100000041 on 28-6-2013 which matures on 27-6-2014 the sum insured was enhanced from ₹ 2,00,000/- to                         ₹ 3,50,000/- and the bonus is ₹ 60,000/- bearing No. 61120034130100000041 on 28-6-2013 which matures on 27-6-2104.   Before the policy was enhanced the complainant underwent medical checkup and they have given certificate that the health conditions of complainant was good and that there is no ailment or preexisting disease and after going through the certificate given by the doctors No. 1 of y9ouu issued policy under the instructions of R2.  So at the time of taking enhanced policy which is only a enhanced policy of the policy taken in the year 2007 from the year of which the complainant did not suffer any preexisting diseases and then the enhanced policy also renewed vide policy No. 61120034142500000024 from 28-6-2014 to 27-6-2015 for continuous coverage and the accumulative bonus is ₹ 67,500/-.  After 14 days of the renewal of the enhanced policy the complainant suffered heart ailment and as per the terms and conditions of the policy in column No. 4.1, it is clearly stated that there will be no coverage if treatment of any pre-existing condition / disease until 48months of continuous coverage of such insured person have lapsed from the date of inception his 1^st policy with us R1. The complainant has taken 8 policies before he suffered heart ailment and so the clause 4 sub clause 1 is not applicable to the complainant.  The complainant submits that he suffered heart ailment on 13-7-2014 after he chad taken renewal of the 8^th enhanced policy after 14 days completed and so it is crystal clear it is not his first policy with R1 the complainant submits column No. 4 of medi claim policy has no applicability for complainants claim. 

4.                     The complainant submits that he suffered heart ailment on 13-7-2014 and was admitted in Fortis Hospital, Bangalore and was discharged on 16-7-2014 and was advised to undergo stunts and accordingly the complainant had taken treatment as advised by Fortis Hospital at Bangalore.  The complainant submits that he has incurred an amount of ₹ 4,74,450/- and subsequently he made a claim under claim No. 74453 on 7-8-2014 for a sum of ₹ 4,81,718/- with R1.   The claim form was sent to R2 for approval by R1, R2 after receiving the claim form from R1 disallowed the enhancement amount in letter addressed to complaint dt.      13-1-2015 stating under the column reasons for disallowance as “enhancement amount not” but it is not stated for what reasons enhancement amount is not considered and it is stated that the amount claimed is                             ₹ 3,95,644/- but whereas per the claim form the complainant claimed ₹ 4,81,718/- and further stated that the approved amount is ₹ 2,60,000/- and the said amount was credited to complainants account lying with Corporation Bank, Kadapa.

5.                     The complainant gave notice through his advocate on 24-1-2015 to respondents and also the Head office of R1 stating that as against sum of ₹ 4,20,000/-  the R2 has credited an amount of ₹ 2,60,000/- only and they have pay the balance amount of ₹ 2,21,718/- or which the R2 gave  reply stating that payable limit of ₹ 2,60,000/- is arrived at basing on the grounds mentioned in column No. 4 of the grounds of the policy relates pre-existing disease at the time of taking of 1^st policy but in the complainant case it is the 8^th policy that is being taken by him with renewal of the enhanced policy amount and so column No. 4 or its sub clause are not applicable with regard to claim of complainant where as in your reply notice you have shown enhancement policy was taken from 28-6-2014 to 27-6-2015 which is incorrect and it is a renewed policy on the enhanced policy and respondents are liable to pay the balance amount of ₹ 2,21,718/-.

6.                     It is therefore, prayed that eh Hon’ble forum may be pleased to allow the complaint in favour of the complainant and against the respondents directing the respondents (a) to pay an amount of ₹ 2,21,718/- towards the balance amount payable to the complainant, (b) to pay an amount of ₹ 1,50,000/- towards mental agony underwent by the complainant (c) to pay an amount of ₹ 5,000/- for notices issued to the respondents, (d) to pay an amount of ₹ 10,000/- towards the costs of the complaint and (e) to grant such other reliefs as the Hon’ble forum deem fit and proper under the circumstances of the case. 

7.                     R1 filed counter that the complaint filed by the complainant is unjust and not maintainable in law or on facts.   The complainant is put to strict proof of all allegations made in complaint which are not expressly admitted herein. 

8.                     This respondent submits that it is true that the complainant has taken policy bearing No. 611200/34/07/20/000000154 and 611200/34/30/00000041 and policy bearing No. 611200/34/30/00000041 matures on 27-6-2014 and before taking that policy the complainant underwent medical cheqkup and certificate is also given stating that there are no ailments and the above policies are issued at the instructions of R2 and it is also true that the policy is being taken by complainant and it is being enhanced from time to time and the last policy bearing No. 611200/34/42/50/0000024 from 28-6-2014 to 27-6-2015 for continuous coverage. 

9.                     This respondent submits that the R2 has come up with a proposal to pay an amount of ₹ 1,36,500/- and so if the complainant agrees for the same then this respondent will pay the same.  This respondent submits that it has to pay the amount in accordance with the direction of R2 and the R2 has sent a proposal for an amount of ₹ 1,36,500/-.  Therefore, prays that this Hon’ble forum may be pleased to dismiss the complaint with exemplary costs. 

10.                   R2 remained absent on 23-11-2015.

11.                   On the basis of the above pleadings the following points are settled for determination. 

1. Whether the complainant is eligible for compensation as prayed by him or not?

                           ii.    Whether there is negligence or deficiency of service on the

                                 part of the Respondents or not?

        iii.    To what relief?

12.              On behalf of complainant Exs. A1 to A8 were marked.  No documents are marked on behalf of the respondents.     

13.              Point Nos. 1 & 2.  As seen from averments of complaint and counter it is very clear that the complainant had taken health insurance policy from R1 and the complainant was regularly renewing the policy without any hindrance up to                 27-6-2013.  The complainant had taken Health Policy for himself and his family members and the policy bearing No. 611200/34/07/20/000000154, which was commenced                     28-6-2007 and maturity period is 17-6-2008 for a sum insured is ₹ 2,00,000/-.  The same was renewed by the complainant up to 28-6-2013 under Ex. A3.  After enhancement the policy is from ₹ 2,00,000/- to ₹ 3,50,000/- policy bearing No. 61120034130100000041, dt. 28-6-2013 matures on 27-6-2014.  Before the complainant had medical checkup by the doctor of R1.  Ex. A4 clearly shows that the complainant underwent treatment in Fortis Hospital, Bangalore and Med Plus, dt.           24-7-2014.  Ex. A7 clearly shows that the policy was enhanced from 28-6-2013 to 27-6-2014 with policy number 61120034130100000041. Ex. A8 clearly shows that the policy bearing no. 61120034142500000024, dt. 28-6-2014 matures on 27-6-2015 also renewed.   From exhibits on record and averments of the complaint and counter it is very clear that the complainant had renewed his policy from ₹ 2,00,000/- to ₹ 3,50,000/- and the policy was in force at the time of ailment of the complainant.  So the respondents 1 & 2 are liable to pay claim of the complainant as prayed by the complainant.  So the complainant is eligible for claim prayed by him as per policy. 

14.                   Point No. 3.  In the result the complaint is allowed, directing the respondents 1 & 2 jointly and severally liable to pay to the complainant ₹ 2,21,718/- (Rupees two lakhs twenty one thousand seven hundred and eighteen only) towards claim amount, pay ₹ 10,000/- (Rupees ten thousand only) towards mental from the agony and pay ₹ 5,000/- (Rupees five thousand only) towards cost of the complaint within 45 days of date of receipt of orders.

                   Dictated to the Stenographer, transcribed by him, corrected and pronounced by us in the open Forum, this the 11^th February 2016.

MEMBER                                       MEMBER                                      PRESIDENT

APPENDIX OF EVIDENCE

Witnesses examined.

For Complainant :   NIL                                          For Respondents :       NIL

Exhibits marked for Complainant: -

Ex: A1         Registered legal notice along with postal cash receipts, Dt. 24-1-2015.

Ex: A2         Acknowledgeements.

Ex: A3         Reply notice of R2 dt. 3-2-2015.

Ex: A4         Bill of Fortis Hospital, and Med Plus, Dt. 24-7-2014.

Ex: A5         Letter addressed by R2 to complaint with regard to approved

amount Dt.13-1-15.

Ex: A6         Claim Form No.74453, Dt. 7-8-2014.

Ex: A7         Enhanced policy bearing No.61120034130100000041 on 28-6-2013

          maturity on27-6-2014.

Ex: A8         Policy bearing no.61120034142500000024, Dt. 28-6-2014 matures on

                   27-6-2015 renewal.

 Exhibits marked on behalf of the Respondents : -  

MEMBER                                           MEMBER                              PRESIDENT                                  

Copy to :-

1. Sri M.A. Ali Khan, Advocate for complainant.

2. Sri A. Rajasekhar,  Advocate for R1.  
3. The In-charge, Claims Department, Good Health Plan Ltd.,

    Plot No. 49, Nagarjuna Hills, Panjagutta, Hyderabad – 82.

B.V.P.