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
Tuesday, 7th June 2016
CONSUMER COMPLAINT No. 83 / 2015
M. Srinivasulu, S/o M. Krishna Murthy,
aged 49 years, Residing at D.No. 18/467,
B.K.M Street, Kadapa. ….. Complainant.
Vs.
1. Bank of Baroda, Rep. by its Manager, C.B. Road,
Opp. Little Flowers School, Chittoor – 517001.
2. Bank of Baroda, Rep. by its Manager, Near 7 Roads, Kadapa.
3. The National Insurance Company Ltd., Rep. by its
Regional manager, Regd. Office 3, Middleton Street,
Post Bok No. 9229, Kolkata – 700 071.
(Regional Manager, Regional Office,
Himayat Nagar, Hyderabad).
(Amended as per orders in I.A. No. 83/2015, dt. 5-11-2015).
4. The Natiioal Insurance Co. Ltd., Rep. by its
Branch Manager, 2nd floor, 10-3-74, PVN Complex,
Sheshapeeran Street, Chittoor - 517 001.
5. The National Insurance Co. Ltd., Rep. by its
Branch Manager, Near Kotireddy Women’s College, Kadapa.
6. The Heritage Health TPA Ltd., Rep. by its
Regional Manager, R.O.510, 5th floor, Babukhan Estate,
Basheerabagh, Hyderabad – 5. ………Respondents
This complaint coming on this day for final hearing on 31-5-2016 in the presence of Sri P. Sekhar Reddy, Advocate for Complainant and Sri P. Goutham Kumar, Advocate for R2 to R5 and R1 called absent on 7-1-2016 and R6 called absent on 18-5-2016 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:- It is submitted that the Complainant is deposit holder in the Bank of R1, R2 is a branch of R1. The R1 bank has tie-up with R3 insurance company for the sake of health policy to its deposit holders. R4 and r5 are the Branch offices of R3. In turn the R3 has tie-up with 3rd party i.e. R6 to provide insurance to the customers of R1 and R2. Accordingly the R3 got issued a group insurance policy in favour bearing No. 552201/98/13/8500000244 for a period of one year starting from 19-12-2013 to 18-12-2014 in favour of under the name and style “Baroda Health Policy” as for the terms and condition Complainant of the policy in case of hospitalization the R3 to R6 are liable to indemnify the expenses incurred by the Complainant.
3. While so, on 22-8-2014 the Complainant admitted in Thulasamma Hospital, Kadapa on the Complainant’s of servre pain in Right Hip. The doctors at Thulasamma Hospital, Kadapa diagnosed the problem of Complainant as a vascular necrosis right hip and conducted surgery of total right hip replacement on 23-8-2014. The Complainant has incurred Rs. 3,49,281/- towards his medical treatment and for hospitalization charges. After the discharge on 20-9-2014, the Complainant contacted with Respondents and submitted all original medical bills, discharge summary and all other relevant documents all with claim form on 28-10-2014. After receipt of claim form from the Complainant, the R3 and R4 have forwarded the same to R6. After the lapse of several months the Respondents did not prefer to settle the claim of Complainant. On that the Complainant got issued a legal notice dt. 10-2-2105 to the Respondents calling upon them to settle his genuine claim. But there was no response from them.
4. To his utter surprise the Complainant has received a letter dt. 18-12-2014 from R6 calling upon him to submit original documents and bills. The Complainant was puzzled after reading the letter. Even though the Complainant submitted all required original documents he was asked to submit the documents once again. With great patience the Complainant submitted reply to the R6 including other bills. Though the R6 received all required documents in original from the Complainant, he has not taken any steps for settlement of medi claim. He has been dragging the matter on one or other pretext. Being the holder of medi claim policy the Complainant is entitled to claim the medical expenses incurred by him for him treatment. The Respondents are deficient nature there are liable to pay the entire expeses incurred by the Complainant towards his hospitalization charges under the above medi-claim policy. The acts of the respondents lead to mental agony and physical strain to the Complainant. The Respondents are liable to pay the compensation to the Complainant for causing mental agony and physical strain. Hence, this complaint.
5. It is therefore, prayed that the Hon’ble forum may be pleased to allow the complaint and pass orders in favour of the Complainant and directing the Respondents (a) to pay the amount of Rs. 3,49,281/- towards hospitalization charges incurred by the Complainant together with 24% interest from the date of making a claim till the date of realization, (b) to pay compensation of Rs. 1,00,000/- for causing physical strain and mental agony and (c) to pay Rs. 3,000/- towards the cost of the complaint and other relief as the Hon’ble forum deems fit and proper in the circumstances of the case.
6. R1 called absent and set exparte on 7-1-2016 and R6 also called absent and set exparte on 18-5-2016.
7. R2 field counter that the complaint made by the Complainant against this respondent is neither just nor maintainable either in law or on facts of the case.
8. The Complainant is put to strict proof of all the allegations mentioned in the complaint which are not expressly and specifically admitted herein by this respondent. It is submitted that the allegation in para – 1 of the complaint that the Complainant is the deposit holder bearing S.B. Account No. 32320100007900 in the bank of R1 and R2 is one of the Branch of Bank of Baroda at Kadapa is true. It is also true that this respondent bank has tie-up with the R3 insurance company for the sake of health policy to its deposit holders and that the R4 and R5 are the branch offices of the R3. The further allegation in the same para that the respondent No. 3 has tie-up with 3rd party i.e. R6 to provide insurance to the customers of R1 and R2 is also true. The other allegation in the same para that the Complainant took group insurance policy issued by R3 bank bearing policy No. 552201/98/13/8500000244 valid from 19-12-2013 to 18-12-2014 under the name of Baroda Health policy is also true but the sum assured in the policy for total family members consisting of Complainant, his wife and two children for a sum of Rs. 3 lakshs.
9. It is submitted that all the other allegations mentioned in para – 2 and 3 have to be strictly proved by the Complainant with all documentary evidence. The allegation that the Complainant has submitted the claim for this respondent or R1 is to be strictly proved by the Complainant, as this respondent has not received any claim form.
10. It is humbly submitted that in all other aspects this respondent is hereby adopting the counter filed on behalf of the R5, in the interests of justice and equity. This respondent therefore, prays that the Hon’ble authority be pleased to dismiss the complaint of the Complainant with exemplary costs against this respondent, in the interests of justice.
11. Counter filed by R5 and the same was adopted by R3 and R4 with a memo. The allegations in the complaint made by the Complainant against this respondent is neither just nor maintainable either in law or on facts of the case. The Complainant is put to strict proof of all the allegations mentioned in the complaint which are not expressly and specifically admitted herein by this respondent.
12. The Complainant is the deposit holder in the bank of R1 and R2 is the branch of R1 is to be strictly proved by the Complainant. The further allegation in the same para that the R1 bank has tie-up with R3 insurance company for the sake of health policy to its deposit holders, that the R4 and R5 are the branch offices of R3 is true. The allegation in the same para that the R3 has tie-up with 3rd party i.e R6 to provide insurance to the customers of R1 and R2 is also true. The other allegations in the same para that the Complainant took group insurance policy issued by R3 bank bearing policy No. 552201/98/13/8500000244 valid from 19-12-2013 to 18-12-2014 under the name of Baroda Health policy is also true but the sum assured in the policy for total family members consisting of Complainant, his wife and two children for a sum of Rs. 3,00,000/-.
13. It is pertinent to note that this is a policy issued by the R1 covering the risk of the group i.e. family members of the Complainant consisting of Complainant, his wife and two children for a sum of Rs. 3 lakhs. As per the terms of the policy which is clearly mentioned in the policy that the benefit for pre-existing disease will accrue only after the completion of 36 months of continuous coverage since the inception of the first policy with this respondent. The maximum sum payable to insurer is case of disease within the ambit of policy would be Rs. 50,000/- only and it may rage higher in case of coverage of insurance for entire family. As per condition 5 (1) of the policy in the event of any misrepresentation, mis-description or non disclosure of any material fact he policy shall be void and all the premiums paid herein shall be forfeited to the company.
14. The Complainant is having an account with Bank of Baroda i.e. R1 at Chittoor. It is true that he is having coverage of mediclaim with the conditions prescribed in the policy. It is submitted that the policy has been issued by R6 in association with this respondent i.e. National insurance company. The Complainant underwent surgery of Right hip which planted at Thulasamma Hospital, Kadapa. The surgery conducted upon the Complainant on 22-8-2014 was said to be a vascular necrosis right hip. He submitted certain papers i.e. claim intimation letter, claim form, hospital discharge summary and bill, current policy copy and bank account details for settlement of his claim to the R6 through the R4. But he has not submitted all the records which include (a) All first consultations and reports, (b) invoice copy of the implant, (c) Xerox copy of complete case sheet, (d) Authorization letter from M.D of hospital to verify all records with investigation reports as per clause 5 (3) (4) of conditions of policy. But he has not chosen to submit the said records enabling the insurer to settle the claim. Hence, a reply letter dt. 18-12-2014 issue db R6 to him clearly mentioning the require documents for settlement of claim in serial number. Further R6 has issued reminder on 8-1-2015 and final reminder 20-1-2015. However, he got issued a notice through his advocate and attempted to avoid the submission of documents. The Complainant is well educated man and he knows terms and conditions of the policy and also its implications. At last the R6 has issued claim closer letter dt. 8-2-2015 to the Complainant intimating that non compliance of query letters and there is no response from the insured and hence, the claim is closed.
15. It is humbly submitted that there must be premedical history before undergoing surgery in Thulasamma Hospital, Kadapa and implantation of hip will not be a sudden result of ailment. In the first instance there must be conservative treatment for the said ailment and it consists of 5 stages and the implantation will be done at 5th stage which is final stage required long duration. Hence, the Complainant has to submit the premedical history. The hospital has to purchase the implants under proper invoice and there must be proof of implantation as this type of operations is rear operations in this type of hospital. Mere certificate or authorized documents will not give right to the Complainant to claim that he underwent certain surgery.
16. The Complainant claiming the amount according to h is whims and fancies. It is false to say that the Complainant has incurred an amount of Rs. 3,49,281/- towards his medical treatment and for hospitalization charges. It is also false to say that the Complainant has submitted all the documents required and the insurer failed to to settle the claim and that the matter has been dragged and the services of the respondent are not insufficient in nature. In any event asking the Complainant to produce the documents legally for settlement of the claim cannot be styled as deficiency in service. In fact the Complainant is avoiding submitting the documents as his claim is false and without basis. The Complainant was informed to produce the documents required for settlement of the claim by the insurer. As he failed to submit the same after giving reasonable opportunity the Respondent have no other option but deny reimbursement. The deny of reimbursement will not amount to deficiency of service. The settlement of claim must be basing on all the documents required and in short fall would entitle the company to deny the claim as the insurance companies are dealing with public money. They are the trustees of public money and they cannot disburse the amount without proof of claim. The repudiation by the company is bonafide and by applying the mind. Hence, the same cannot be challenged before this Hon’ble authority.
17. All the allegations in the complaint which are not specifically denied are all false and invented. Suffice it to say that the Complainant has to prove his case on his own documents and absolutely not document is forthcoming to show the alleged claim is genuine. Therefore, this Respondent prays that the Hon’ble authority be pleased to dismiss the complaint of the Complainant with exemplary costs against this respondent, in the interests of justice.
18. On the basis of the above pleadings the following points are settled for determination.
- Whether the complainant is eligible for compensation as prayed by him or not?
- Whether there is negligence or deficiency of service on the part of the Respondents or not?
- To what relief?
19. On behalf of complainant Exs. A1 to A6 were marked and on behalf RW1 was examined and Exs. B1 to B5 documents were marked.
20. Point Nos. 1 & 2. It is very clear from Ex. A1 that the Complainant is the policy holder of R3 Company. The policy commences from 19-12-2103 to 18-12-2014 policy bearing No. 552201/98/13/8500000244 under the name and style of policy “Baroda health policy”. It is very clear from Ex. A2 and A3 the Complainant underwent treatment at Thulasamma Hospital, Kadapa. The discharge summary, bills discloses that the Complainant had paid Rs. 3,49,281/- towards total bill at Thulasamma Hospital, Kadapa. As per documents on record the policy was in force at the time of surgery of the Complainant. Dr. Nagesh, who was witness of the respondent he himself deposed that he is not, treated the Complainant at any time. Generally people will go for health insurance policy, that will provide financial aid when they have illness; here the Complainant policy did not the same. He had taken policy covers up to Rs. 3,00,000/-. The policy was inforce at the time of replacement of hip i.e. on 23-8-2014. The Complainant had incurred Rs. 3,49,281/- for medical treatment under Ex. A3. As seen from documentary evidence on record the Complainant has eligible for compensation as prayed by him. As per policy the claim is only up to Rs. 3,00,000/-. So the Complainant has eligible for compensation of Rs. 3,00,000/- at the same time there is deficiency of service or negligence on the part of the Respondents.
21. Point No. 3. In the result the complaint is allowed, directing the Respondents 1 to 6 jointly and severally liable to pay Rs. 3,00,000/- (Rupees three lakshs only) towards policy claim to the Complainant, pay Rs. 25,000/- (Rupees twenty five thousand only) towards mental agony and physical strain to the Complainant, to pay Rs. 3,000/- (Rupees three thousand only) towards costs 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 7th June 2016.
MEMBER MEMBER PRESIDENT
APPENDIX OF EVIDENCE
Witnesses examined.
For Complainant : NIL
For Respondents :
RW1 Dr. G. Nagesh- RW1 on 13-4-2016
Exhibits marked for Complainant: -
Ex.A1 Attested copy of insurance policy issued by 3rd Respondent.
Ex.A2 Attested copy of Discharge Summary dated 20-09-2014 issued Thulasamma Hospital, Kadapa.
Ex.A3 Attested copy of Discharge bill for Rs.3,49,281/- and stickers of implant issued by Thulasamma Hospital, Kadapa.
Ex.A4 Legal notice Dated 10-02-2015 issued by the complainant to the Respondents (two in number) and two postal receipts and two acknowledgement cards.
Ex.A5 Letter dt. 18-12-2014 issued by 6th Respondent to the complainant.
Ex.A6 Photos of operated (R ) Hip of the complainant.
Exhibits marked on behalf of the Respondents.
Ex.B1 P/c of bearing No.552201/48/13/8500000244 along with terms and conditions issued by 3rd respondent.
Ex.B2 P/c of Reminder letter dt. 18-12-2014.
Ex.B3 P/c of Reminder letter dated 8-1-2015.
Ex.B4 P/c of Final Reminder letter dated 20-1-2015.
Ex.B5 P/c of Claim closer letter dated 8-2-2015.
MEMBER MEMBER PRESIDENT
Copy to :-
- Sri P. Sekhar Reddy, Advocate for complainant.
- Sri P. Goutham Kumar, Advocate for R2 to R6.
- Bank of Baroda, Rep. by its Manager, C.B. Road,
Opp. Little Flowers School, Chittoor – 517001.
B.V.P.
