Date of filing: 7.03.2013.

Date of disposal: 23.07.2013.

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM - II:

VIJAYAWADA, KRISHNA DISTRICT

Present: Sri A. M. L. Narasimha Rao, B.Sc., B. L., President

Smt N. Tripura Sundari, B. Com., B. L., Member

Tuesday, the 23th day of July, 2013

C.C.No.36 of 2013

Between:

Tadepalli Bala Krishna Rao, S/o Lakshmi Narayana, Hindu, Aged 62 years,

R/o.D.No.27-17-5, Peddibotlavari Street, Governorpet, Vijayawada - 2.

…… Complainant.

And

1. M/s Good Health Plan Ltd., Rep: by its Manager, Plot No.49, Nagarjuna Hills,

Panjagutta, Hyderabad – 500082.

2. The Branch Manager, Andhra Bank, Congress Office Road, Governorpet,

Vijayawada – 2.

…. Opposite parties.

This complaint coming on before the Forum for final hearing on 17.7.2013, in the

presence of Sri K. Kishore Kumar, advocate for complainant; Sri P. Rama Mohan Rao,

advocate for 1st opposite party; Smt A.S. Rani, advocate for 2nd opposite party and upon

perusing the material available on record, this Forum delivers the following:

O R D E R

(Delivered by Hon’ble President Sri A. M. L. Narasimha Rao)

1. This complaint is filed under Section 12 of Consumer Protection Act, 1986 for a

direction to the opposite parties to pay a sum of Rs.29,974/- with interest thereon and to

pay costs.

2. The averments of the complaint in brief are as follows:

The complainant has savings bank account in the 2nd opposite party bank. It has

AB Arogyadaan Policy cover under tie up with the 1st opposite party. The complainant

has policy for five years and last policy was renewed on 13.10.2011 and valid up to

12.10.2012. Under that policy the complainant was entitled to cashless hospitalizationin selected hospitals and reimbursement of the amount spent in case of demand in nonselected hospitals. The complainant developedswelling with mild pain in the crotum

firstly on 5.6.2012. He consulted Dr Rasik Sangvi, who advised to undergo hydrocele operation. The complainant got medical checkup as advised by the doctor in CureDiagnostic center on 5.6.2012 and incurred an expenditure of Rs.2,050/-. The2

complainant obtained second opinion and consulted Dr D.K.V. Prasad of Aswini hospitalon 7.6.2012. He also advised hydrocele operation.The doctor advised the complainantto get blood examination, ECG scan etc. In that regard the complainant spent

Rs.1,130/-. He joined in Aswini hospital on 8.6.2012 and Bilateral Hydrocele operationwas done on 9.6.2012 and the complainant was discharged on 13.6.2012. Thecomplainant spent a sum of Rs.31,500/- towards hospitalization and medicines. He was

advised to take medicines for 10 days further. He purchased medicines on 14.6.2012,15.6.2012 and 18.6.2012 spending a total sum of Rs.3,536/-. The complainant made a claim for Rs.38,216/- and sent the bills to the 1st opposite party. It has approved the claim for Rs.23,229/- only and the remaining claim was repudiated. The approved amount was credited to the SB account of the complainant maintained with the 2nd opposite party and it was intimated to the complainant on 12.9.2012. Reason for part repudiation and disallowing the claim was not noted in the letter. The 1st opposite party sent a discharge voucher to cancel the receipt of the amount of Rs.23,229/- towards full and final settlement. The complainant wrote a letter on 18.9.2012 to the 1st opposite party stating that he is entitled to claim up to Rs.1,00,000/- under the policy and that the 1st opposite party is bound to indemnify the complainant for the total claim amount. Asthere is no suitable reply from the 1st opposite party this complaint is filed.

3. The 1st opposite party filed its version denying the allegations made in thecomplaint and further stating as follows:

The complainant suffered pre-existing ailment. As per the terms and conditionsthe loan of the 1st opposite party was liable to pay only Rs.23,229/-. The complainant isaged 63 years. In respect of persons above 60 years 20% is deductable. After scrutiny

of the documents the 1st opposite party repudiated the claim informing the complainanton 12.9.2012 the reason for disallowing the claim for Rs.14,987/-. There is nodeficiency in service on the part of this opposite party. The complainant has notproduced breakup figures for the medicines charges of Rs.3,500/-. The complainant didnot produce receipts for investigation charges of Rs.3,180/- during pre- hospitalization

period. There are no prescriptions and the break up individual charges includingamount of Rs.2,000/- towards OT consumables. The dispute is only money matter and the complainant has to file civil suit. The complainant was also suffering from diabetes. They show that he has pre existing ailment. The amounts was claimed by thecomplainant is excessive. This complaint is liable to be dismissed.

4. The 2nd opposite party filed version generally admitting all the allegations madeas true and correct and further stating that the amount of Rs.23,229/- approved by the1st opposite party was transferred to the complainant’s SB account and it was intimated to the complainant that the complaint be disposed off with compensatory costs.

3

5. The complainant filed his affidavit as deposition of PW-1. The Director of the 1stopposite party filed his affidavit as deposition of DW-1. Exs.A1 to A19 are marked and Exs.B1 and B2 are marked on behalf of the 1st opposite party.6. Heard the arguments advanced by the learned counsel for all the parties 

7. The points for determination are: 1) Whether the 1st opposite party is not justified in repudiating the claim to an

extent of Rs.14,987/- and if there is deficiency in service on the part of the 1st opposite party?

2) Whether the complainant is entitled to the compensation as claimed?

Point No.1: 8. The complainant was admittedly a savings bank account holder in 2nd opposite party bank. The account said to have policy coverage. According to the complainant he has such policy coverage for five years. The last coverage was from 13.10.2011 to 12.10.2012. The complainant had undergone hydrocele operation in Aswini hospital of Dr D.K.V. Prasad. Before undergoing operation he consulted Dr. Sangvi and on his advice he got medical checkup he spent Rs.2,050/-. Aswini hospital seems to have

issued a bill for Rs.31,500/- under Ex.A5 final bill statement. The opposite party has sent a letter dated 12.9.2012 under Ex.A4 stating that an amount of Rs.14,987/- was disallowed. The disallowed items are medicines by hospital for a sum of Rs.3,500/-,

laboratory charges of Rs.3,180/- OT consumable value of Rs.2,000/- and file admission of Rs.500/-. The first 3 items were disallowed on the ground that there was no break up. The 4th item was disallowed for the reason noted as N/P. The balance amount was

sent to the complainant and he issued discharge voucher original of Ex.A15. Thecontention of the complainant is that the 1st opposite party cannot disallow the amounts mentioned in the final bill statement of the hospital.  9. There are certain terms mentioned on the reverse of the policy Ex.B1. Since the hydrocele operation was performed more than 12 months after taking the first policy the claim is not excluded under Clause.4.3 of Ex.B1. According to the 1st opposite party the complainant is aged 63 years and therefore “20% deductable” applied under clause 5.1 of Ex.B1. In Ex.A4 it is specifically mentioned that in respect of persons above 60 years 20% deductable will be applied on all admissible claims. The complainant was admittedly more than 60 years by the time of taking treatment. So after ascertaining

admissible amount 20% has to be deducted. The learned counsel for the opposite party also submits that as there was no break up figures in some of the amounts noted by the hospital, the 1st opposite party could not approve the claim for those amounts. Clause

4.11 of Ex.B1 states that expenses on vitamins and tonics unless forming part of

4 treatment for injury or disease as certified by the attending physician are excluded.

Ex.A5 does not contain the details of pharmacy amounts or OT consumables. That apart in Ex.A4 copy of essentiality certificate issued by same hospital on 13.6.2012, the pharmacy bills is noted as Rs.2,500/- as against Rs.3,500/- noted in Ex.A5. Therefore it

would be proper to allow the amount of Rs.2,500/- as pharmacy bills. The opposite

party has not given the list of documents received from the hospital. If they received copy of case sheet it would certainly contain the details of medicines used during the period of treatment. The opposite party has not produced copies and has not asked the

complainant to produce them in the Forum.

10. The laboratory charges of Rs.3,189/- was disallowed on the reason of no break up. The complainant filed Ex.A7 receipt issued by Aswinin hospital on 7.6.2012 for Rs.1,130/- and Ex.A12 receipt issued by Cure Diagnostic center on 5.6.2012 for Rs.2,850/-. While Ex.A12 receipt was taken for the profile of diagnostic Ex.A7 wasissued relating to several tests including ECG and blood test. On 5.6.2012 there was

no diagnosis of hydrocele and the tests were done only to know if there are any ailment.Therefore the tests undergone on 5.6.2012 at Cure diagnostic center cannot be addedin the claim. Then the complainant is entitled to the amount of Rs.1,130/- laboratory

charges.

11. The 1st opposite party does not say which type of item in OT consumables has tobe disallowed and which item has to be proved. In the absence of any such statement blank denial of the amount towards OT consumables cannot be accepted. Thereforethe complainant is entitled to the amounts Rs.2,000/- claimed towards OT consumable.The amount of file admission cannot be covered by hospitalization charges. Therefore

the complainant is entitled Rs.2,500/- towards medicines, Rs.1,130/- towards laboratorycharges and Rs.2,000/- OT consumables. They total to Rs.5,630/-.12. The complainant’s claim includes the amount of bills under Exs.A8 to A11 for

purchase of medicines on 14.6.2012, 15.6.2012 and 18.6.2012 on the ground that thesemedicines were purchased as advised by Dr DKV Prasad who performed surgery.Therefore they are part and parcel of hospitalization expenses. In clause 5.1 of Ex.B1

there is reference to pre and post hospitalization expenses and according to this clauseit appears the pre and post hospitalization expenses are admissible to the extent of 10%of sum assured. Since the sum assured is Rs.1,00,000/- the pre and post

hospitalization expenses can be allowed up to Rs.10,000/-. Exs.A8 to A11 are issuedfor a total sum of Rs.3,526/-. So it is permissible. In fact it was included by the 1stopposite party.  13. The complainant’s claim consists of Rs.31,500/- paid to hospital, Rs.2,050/- for

the lab reports on 5.6.2012, Rs.1,130/- for the lab report on 7.6.2012 and Rs.3,536/- the cost of post-hospitalization medicines. The total claim was Rs.38,216/-. In Ex.A14 this 5 amount of Rs.38,216/- is noted as the amount claimed. Disallowed amount is

Rs.9,180/-. According to above calculation the sum of Rs.5,630/- could not be disallowed. Only Rs.3,500/- could be disallowed. The balance comes to Rs.34,666/-. As per clause 5.1 of Ex.B1 ‘20% deduction’ has to be applied as the complainant is

aged more than 60 years. So Rs.6,933.20 ps has to be deducted towards ‘20% deduction’. The balance comes to Rs.27,732.80 ps. The first opposite party paid Rs.23,229/-. The 1st opposite party should still pay Rs.4,503.80 ps rounded of to

Rs.4,500/-. Therefore it has to be said that there is deficiency in service on the part of the1st opposite part.

Point No.2:

14. In view of the answer on point no.1, the complainant is entitled to a further a sum of Rs.4,500/- and interest thereon from 12.9.2012 the date of sanction of a part of the claim and costs at Rs.1,000/-

15. In the result this complaint is allowed in part and the 1st opposite party is directed to pay a sum of Rs.4,500/- (Rupees four thousand and five hundred only) with interest thereon at the rate of 9% p.a., from 12.9.2012 till realization or payment and to pay Rs.1,000/- towards costs to the complainant. The amounts awarded shall be paid within one month from the date of receiving copy of this order. Complaint for rest of the relief and against the 2nd opposite party is dismissed.

Dictated to Steno N. Hazarathaiah, transcribed by him corrected by me and pronounced by us in the open Forum, this the 23rd day of July, 2013.

PRESIDENT                                                                                    MEMBER

Appendix of evidence

Witnesses examined

For the complainant:                                 For the opposite parties:

Tadepalli Bala Krishna Rao,                      The Director of OP.1, (by affidavit)

PW-1,(by Affidavit)

Documents marked

On behalf of the complainant:

Ex.A1 Photocopy of AB Arogyadan card.

Ex.A2 19.06.2012 Photocopy of letter issued by complainant to OP.

Ex.A3 13.06.2012 Photocopy of discharge summary.

Ex.A4 13.06.2012 Photocopy of essentiality certificate.

Ex.A5 13.06.2012 Photocopy of final bill statement.

Ex.A6 07.06.2012 Photocopy of ECG report.

Ex.A7 07.06.2012 Photocopy of receipt issued by Aswini Diagnostics.

Ex.A8 14.06.2012 Photocopy of medical bill.

Ex.A9 14.06.2012 Photocopy of cash bill issued by City Drug House.