State Consumer Disputes Redressal Commission
Pps Hari Prasad vs New India Assurance Co. Ltd on 21 March, 2018
Cause Title/Judgement-Entry STATE CONSUMER DISPUTES REDRESSAL FORUM Telangana First Appeal No. FA/253/2014 ( Date of Filing : 28 Apr 2014 ) (Arisen out of Order Dated in Case No. of District State Commission) 1. PPS Hari Prasad Son of Late P Krishnamurty Sastry Aged 79 years Occ retired executive 30-36 Thirumal nagar Kanajigud Military Dairy Farm Road Secundrabad ...........Appellant(s) Versus 1. New India Assurance Co. Ltd 87 Mahatma Gandhi Road Fort Mumbai 400001 2. New India Assurance Co. Ltd 206 Chenoy Trad centre Park lane Secunderabad 500003 3. Good Health Plan Ltd Plot no 49, ngarjuna Hills, Punjagutta, Hyderabad 500082 4. INSURANCE REGULATORY DEVELOPMENT AUTHORITY Parisrama Bhavan Basheerbagh Hyderabad 500001 ...........Respondent(s) BEFORE: HON'BLE MR. JUSTICE B. N. RAO NALLA PRESIDENT HON'BLE MR. Sri. PATIL VITHAL RAO JUDICIAL MEMBER For the Appellant: For the Respondent: Dated : 21 Mar 2018 Final Order / Judgement STATE CONSUMER DISPUTES REDRESSAL COMMISSION OF TELANGANA : At HYDERABAD FA 253 of 2014 AGAINST CC . 466 of 2012, DISTRICT FORUM III, HYDERABAD Between : PPS Hariprasad, Son of Late P. Krishnamurthy Sastry Aged 79 years, Occupation : Retired Executive 30-46, Thirumal Nagar Kanajiguda, Military Dairy Farm Road Secunderabad - 500 015 .. Appellant/complainant And New India Assurance Co. Ltd 87, Mahatma Gandhi road, Fort : Mumbai - 400 001. New India Assurance Co. Ltd 206, Chenoy Trade Centre, Park lane, Secunderabad - 500 003. Good Health Plan Ltd Plot no. 49, Nagarjuna Hills, Punjagutta, Hyderabad - 500 082. Insurance Regulatory Development authority Parisrama Bhavan Basheerbagh, Hyderabad - 500 001 . .. Respondents/opposite parties Counsel for the Appellant : M/s. Neeraj Naidu Counsel for the Respondents : Smt. S. N. Padmini for R1 and R2. R3 - not pressed. R4 - served. Coram : Honble Sri Justice B. N. Rao Nalla ... President And Sri Patil Vithal Rao ... Member
Wednesday, the Twenty First Day of March Two Thousand Eighteen Oral order : ( per Hon' ble Sri Justice B.N.Rao Nalla, Hon'ble President ) ***
1) This is an appeal filed under Section 15 of the Consumer Protection Act by the complainant praying this Commission to modify the impugned order dated 27.03.2014 passed in CC 466 of 2012 on the file of the DISTRICT FORUM -III, Hyderabad and to award Rs.23,400/- towards balance of claim and Rs.40,000/- towards balance compensation against the opposite parties 1 and 4 and direct the opposite party No. 4 to ensure and enforce uniform policy for re-imbursement for each illness in any Medi-claim policy, whether apolicyis for Senior Citizens or for others, subject to an aggregate limit, different for each category.
2) For the sake of convenience, the parties are described as arrayed in the complaint before the District Forum.
3). The case of the complainant, in brief, is that he obtained a Senior Citizen Medi Claim Policy bearing No. 61240034111600000012 from the second opposite party for himself and his wife and it was renewed from time to time. The first opposite party approved only Rs.10,000/- for cataract surgery of his each eye which was sub limit allowable for cataract surgery for a senior citizen with the aggregate limit of Rs.1,50,000/- under the policy at his request through second opposite party. Whereas, this sub limit for cataract surgery for medi-claim policy holders ( other than Senior citizens) is Rs.24,000/-. Hence he has chosen Rs.23,000/- package and requested to treat Rs.10,000/- as cashless and he will pay the balance in cash to " Drishti Eye Clinic". He was told the cataract facility was available only for Corporate Hospitals and not for "Drishti Eye clinic". He underwent surgery for right eye on 28.03.2012 and for the left eye on 06.04.2012. The opposite party no. 3, the third party administrator did not settle the claim. He settled his claim for Rs.18,000/- on 05.05.2012 after deducting 10% of admitted claim of Rs.2,000/- only after intervention of second opposite party at his request which amounts to deficiency in service on the part of all opposite parties. Hence the complaint to direct the opposite parties to pay the damages of Rs.50,000/- with interest @ 12% pa, to pay the remaining Rs.28,000/- out of Rs.46,000/- ( for two eyes) which is aggregate sub limit to other citizens, to direct opposite party nos. 1, 2 and 4 to terminate the services of present TPA, i.e, OP no. 3 and opposite party no. 1 and 2 to take over the services rendered by TPA and to award costs.
4). The opposite parties 1 and 2 opposed the above complaint by way of written version, which was adopted by opposite party no. 3, while admitting that the complainant underwent cataract surgery for both eyes and his Senior citizen Medi claim policy was in force and his claim was settled for a sum of Rs.18,000/- @ Rs.9,000/- each eye and maximum amount payable is only 10,000/- each eye and there is 10% co-payment, contending that the cashless facility is provided in the list of hospitals which was attached along with a TPA card sent by the third party administrator (GHPA) at the time of issuance of I-Card and the Drishti Eye Clinic is not in the list of hospital of the TPA and hence the reimbursement has to be claimed. The complainant mis-understood the reason for not providing cashless facility. There is no deficiency in service on their part and hence prayed to dismiss the complaint.
5). The opposite party no. 4 contended that it was established under IRDA Act, 1999 and it has to perform statutory conventions under the said Act and as such it cannot be said to be rendering any services for consideration as contributed under section 2 (1) (O) of the C.P.Act., 1986 and it has relied on various decisions in that regard. There is no relationship between the consumer and the OP No. 4 and hence prayed to dismiss the complaint against it.
6) During the course of enquiry before the District Forum, in order to prove his case, the complainant filed his evidence affidavit and got marked Ex.A1 to A-8. Written arguments on behalf of the complainant were filed. Heard both sides
7) The District Forum, after considering the material available on record, held and directed the third opposite party to pay Rs.10,000/- towards compensation and costs of Rs.5,000/- towards costs within 30 days, failing which, it shall carry interest @ 9% pa from 01.05.2014 till realization.
8) Dissatisfied with the said order, the complainant preferred this appeal before this Commission.
9). Heard the counsel for the appellant/complainant and he also filed written arguments.
10) The points that arise for consideration are, (i) Whether the impugned order as passed by the District Forum suffers from any error or irregularity or whether it is liable to be set aside, modified or interfered with, in any manner? (ii) To what relief ? 11). Point No.1 :
There is no dispute that the appellant/complainant obtained a Senior Citizen Medi Claim Policy bearing No. 61240034111600000012 from the second opposite party for himself and his wife. There is no dispute that he undergone cataract surgery for his two eyes and the second opposite party approved Rs.10,000/- to each eye for cataract operation.
12). The contentions of the appellant/complainant is that he was denied cashless treatment, he was allowed only Rs.10,000/- for cataract surgery of his each eye which was sub limit allowable for cataract surgery for a senior citizen with the aggregate limit of Rs.1,50,000/- under the policy, whereas , it is Rs.24,000/- other than Senior citizens and further his claim settled for Rs.18,000/- on 05.05.2012 after deducting 10% of admitted claim of Rs.2,000/- only after intervention of second opposite party which amounts to deficiency in service. On the other hand, the opposite parties rebutted that the cashless facility is provided in the list of hospitals which was attached along with a TPA card sent by the third party administrator (GHPA) at the time of issuance of I-Card and the Drishti Eye Clinic is not in the list of hospital of the TPA and hence the reimbursement has to be claimed. Further, the TPA services have to be availed as per the rules and guidelines of IRDA. 10% is deductible towards co-payment. Probably, the appellant might have misunderstood the terms and conditions.
13). The District Forum observed that since the appellant/complainant voluntarily opted for the policy and the terms and conditions, he is not entitled to other options except finding fault with the third respondent/third opposite party for not reimbursing the amount immediately and that too only after intervention of the second respondent/second opposite party and hence granted compensation against it.
14). The Complainant in the appeal grounds targeted the first respondent/1st opposite party and the fourth respondent/4th opposite party that they are promoting and practicing unfair trade practice. The main contention of the appellant/complainant is that though the Senior Citizens were allowed to sanction of Rs.10,000/- per each eye cataract surgery, but, other than senior Citizens are entitled to Rs.24,000/-. Further, as per the least package offered by the Dhristi Eye Clinic may be Rs.23,000/- and the insured sum is Rs. 1,50,000/-, but, as per the policy conditions he is entitled to Rs.10,000/- only per each cataract surgery. The appellant/complainant himself opted for such policy. Admittedly, the said Dhristi Eye clinic was subsequently included in the list of approved hospitals after filing the complaint. This Commission cannot change the terms and conditions and would see whether there is any deficiency in service as per the terms and conditions in between the parties. The appellant in his written arguments also claimed for cataract surgery of his wife, who has undergone surgery in 2014, after two years of filing of his complaint, which is not entitled by her in this appeal and she has to file another complaint before the District Forum, if she has any grievances in that connection. If the appellant/complainant had approached the approved hospital, then, this type of problem would not have arisen.
15). After considering the foregoing facts and circumstances and also having regard to the contentions raised on both sides, this Commission is of the view that there is no infirmity or irregularity in the impugned order. There are no merits in the appeal and hence it is liable to be dismissed.
16). Point No. 2 :
In the result, the appeal is dismissed confirming the impugned order dated 27.03.2014 in CC 466 of 2012 passed by the District Forum- III, Hyderabad. There shall be no order as to costs. Time for compliance four weeks.
PRESIDENT MEMBER Dated : 21.03.2018. [HON'BLE MR. JUSTICE B. N. RAO NALLA] PRESIDENT [HON'BLE MR. Sri. PATIL VITHAL RAO] JUDICIAL MEMBER