Date of filing: 20.7.2017 Date of Order : 19.7.2018
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, B.L., LADY MEMBER
THURSDAY THE 19th DAY OF JULY, 2018
CONSUMER COMPLAINT No. 63 / 2017
Suresh Babu Narayana, S/o Subramanyam,
aged 63 years, Hindu, retired APGB Bank Manager,
Residing at Flat No. 307, Keerthi Residency,
Co-colony, Kadapa City and District. ….Complainant.
Vs.
1. National Insurance Co. Ltd., Rep. by its
Branch Manager, 1st floor, 40/343, Tula Xomplex,
Gandhinagar, Kurnool, AP 518001.
2. The Manager, MD India Health Insurance TPA private Ltd,
H.No. 6-3-883/A/1, Imperial Plaza, Flat No. 103,
1st floor, Beside Topaz Building, Panjagutta,
Hyderabad – 500082. ….. Opposite parties.
This complaint coming for final hearing on 11-7-2018 in the presence of Sri G. Vijaya Maruti Reddy, Advocate for complainant and Sri P. Goutham Kumar, Advocate for Opposite parties and upon perusing the material papers on record, the Forum made the following:-
O R D E R
(Per Sri V.C. Gunnaiah, President),
1. The complainant filed this complaint under section 12 of Consumer Protection Act, 1986 (for short herein after called as C.P. Act) to direct the opposite parties to pay a sum of Rs. 1,07,588/- with interest at 24% p.a. to pay a sum of Rs. 10,000/- towards compensation and grant costs of this complaint.
2. The brief averments of the complaint are as follows:-
The complainant is retired APGB Bank Chief Manager and O.P.1 is doing business in General Insurance policy having branches throughout India one at Kadapa and O.P.2 is 3rd party agent of O.P.1 company. The complainant is medi claim policy holder of O.P.1 vide policy No. 552300/48/15/8500000474 since 1995. The policy covers the medi claim risk of the complainant’s family viz., himself, his wife and daughter and has been paying the premiums to keep the policy for lives since 1995. The policy covers risk amount upto Rs. 3,00,000/- to each member of the family. The complainant has also obtained no claim bonus to the tune of Rs. 1,50,000/- each as no claim was made.
3. While so the complainant’s wife S. Siraj Begum, underwent cataract surgery for her left eye on 18.01.2017 and to her right eye on 27.01.2018 at Maxi Vision eye Hospital, Somajiguda Hyderabad and complainant incurred Rs. 83,630/- and Rs. 72,588/- totaling Rs. 1,56,218/- for the above two operations. The complainant submitted the claim to O.P.2 on 21.01.2017 and also on 15.02.2017 respectively for payment of expenditure incurred by him. But they did not pay. Later on persuasions by complainant they settled claim at Rs. 24,000/- + Rs. 24,630/- in total Rs. 48,430/- Still the opposite parties have to pay Rs. 1,07,558/- to the complainant under mediclaim policy. The complainant brought the same to the notice of O.P.1 and in inspite of repeated demands the opposite parties did not settled the actual expenditure incurred by the complainant for which he is entitled for an amount of Rs. 1,07,588/- balance. Hence, the complaint for the above reliefs.
4. opposite parties 1 & 2 filed separate written version / counters but with the same contents in verbatim.
5. Opposite parties 1 & 2 filed counter admitting that they issued mediclaim policy to the complainant vide policy No. 552300/48/15/8500000474 as pleaded by the complainant but denied other allegations regarding not settled the claim negligence on their part etc., and called upon the complainant to prove all of them.
6. It is further averred that there is an arbitration clause in the terms and conditions of the policy, so complaint is not maintainable. It is not denied the complainant incurred total Rs. 1,56,218/- for the operations of both eyes of complainant’s wife. The complainant took the national medi claim policy valid from 28.3.2016 to 27.9.2017 with certain terms and conditions. The complainant is entitled for claim under preferred provider network package for insured persons and there is list available with the hospitals with the opposite parties. Complainant is entitled for treatment in PPN hospitals for Mono focal PPN Package (cataract). But the complainant has underwent Multi Focal surgery which is not covered under the PPN package policy as such these opposite parties settled the claim for Mono Focal PPN package and paid total Rs. 48,630/-. As such the complainant is not entitled to any claim beyond that amount as per the terms and conditions of the policy. The complainant voluntarily received the amount for final settlement of his claim and satisfied. Hence, the complaint is not maintainable for more amounts. Therefore, the complaint is liable to be dismissed.
7. No oral evidence has been let in by the parties. But affidavit of complainant filed and got marked Exs. A1 to A5 and on behalf of the opposite parties 1 & 2 filed affidavits and got marked Ex. B1 and closed their evidence. Written arguments not filed by the complainant but opposite parties filed written arguments.
8. Heard arguments on both sides and perused the material on record placed by the parties and considered written arguments filed by the opposite parties.
9. On the above pleadings the following points are settled for determination.
- Whether is there any deficiency of service on the part of opposite parties as pleaded by the complainant?
- Whether the complainant is entitled for the reliefs claimed against Opposite parties, if so what extent?
- To what relief ?
10. Point Nos. i and ii: These two points are connected to each other, hence, they are discussed together for the sake of convenience and better understanding.
11. There is no dispute that the complainant obtained mediclaim policy as per Ex. A1 from the opposite parties and it was valid for the cataract operation to the wife of the complainant’s eyes. It is also not in dispute that the complainant’s wife S. Siraj Begam underwent cataract surgery to her both eyes on 18.01.2017 and 21.07.2017 and incurred an expenditure of Rs. 1,56,218/- and the complainant claimed the said amount under mediclaim policy under Ex. A1 by producing Ex. A2 bills. But the opposite parties paid Rs. 24,000/- + Rs.24,630/- totaling Rs. 48,630/- and refused to pay the balance of Rs. 1,07,588/-.
12. It is contended by the complainant that the opposite parties cannot refuse to pay Rs. 1,07,588/- by paying Rs. 48,630/- towards total claim of the complainant for cataract operations of his wife, which are covered under mediclaim policy of opposite parties both as per Ex. A1 & B1. Therefore, the refusal of claim of complainant by opposite parties amounts to deficiency in service as such the complainant is entitled for the same.
13. On the other hand the learned counsel for opposite parties contended that there was arbitration clause in the terms and conditions of the policy and that was not followed by the complainant and having received Rs. 48,630/- towards full satisfaction of the claim the complainant cannot file this complaint. So no deficiency in service on the part of the opposite parties and complaint is liable to be dismissed.
14. It is not doubt true that the complainant received Rs. 48,630/- from the opposite parties against his claim of total Rs. 1,56,218/-. As per Ex. A2 bills filed by the complainant he proved that he has incurred total Rs. 1,56,218/- towards cataract operation of his wife S. Siraj Begum. As per Ex. B1 & A5 also under Ex. A1 issued by opposite parties covers cataract operations also. Though a contention was raised by the opposite parties that the complainant is entitled for mono focal PPN package (cataract) and not for multi focal surgery underwent by the complainant’s wife, therefore, the claim was restricted to Rs. 48,630/- only, so the complainant is not entitled for balance of Rs. 1,07,588/-. But his contention cannot be upheld as there is no mention in terms and conditions of policy as per Ex. B1 and Ex. A5 that the policy holder is not entitled for Multi focal surgery. As seen from Ex. A5 & B1 terms and conditions the complainant is entitled for cataract operations. In this case the complainant’s wife underwent cataract operations only. So the opposite parties cannot refuse the balance claim of Rs. 1,07,588/- as claimed by the complainant. Refusing the medi claims on one pretest or other by the opposite parties cannot be encouraged and the insurance companies cannot avoid the medi claims on flimsy grounds having received premiums regularly from the policy holders. Therefore, refusing the claim of the complainant by opposite parties in this case amounts to deficiency in service. Hence, the complainant is entitled for the balance claim of Rs. 1,07,588/- from the opposite parties.
15. Coming to the next contention since arbitration clause was there in terms and conditions of the policy, this complaint is not maintainable is also unsustainable. Simply because there was clause of arbitration the same cannot preclude the policy holder i.e. complainant herein from approaching the consumer forum in settling his claim and that the clause of arbitration is not a hurdle and seeking redressal of his grievances in this Forum. Hence, we hold the complaint is maintainable. Accordingly, points 1 & 2 are answered against the opposite parties and in favour of complainant.
16. Point No. iii:- In the result, the complaint is allowed directing the opposite parties 1 & 2 to pay Rs. 1,07,588/- (Rupees one lakh seven thousand five hundred and eighty eight only) along with interest at 9% p.a. from 20.7.2017 i.e. date of filing of the complaint till realization and shall also pay Rs. 5,000/- (Rupees five thousand only) towards compensation and Rs. 5,000/- (Rupees five thousand only) towards costs of the complaint to the complainant. The opposite parties 1 & 2 shall pay the above amounts within 45 days from the date of receipt of this order.
Dictated to the Stenographer, transcribed by him, corrected and pronounced by us in the open forum, this the 19th day of July, 2018.
MEMBER PRESIDENT
APPENDIX OF EVIDENCE
Witnesses examined
For complainant : NIL For opposite party : Nil
Exhibits marked on behalf of the Complainant :-
Ex: A1 The copy of policy copy valid from 28-03-2016 to 27-3-2017.
Dt.17-03-2016.
Ex: A2 P/c of Medical Bills,
Ex: A3 The copy of E-Mail correspondence dt.19-05-2017.
Ex: A4 P/c of letter from complainant to opp party no.1 dt.22-03-2017.
Ex: A5 P/c of Mail- claim insurance policy terms and conditions filed by the opp. party and the copy furnished to me.
Exhibits marked on behalf of the O.Ps :–
Ex: B1 Attested copy of National Mediclaim policy copy along with terms
and conditions.
MEMBER PRESIDENT
Copy to
1) Sri G. Vijaya Maruthi Reddy, Advocate for complainant.
2) Sri P. Goutham Kumar, Advocate for opposite parties.
B.V.P
