State Consumer Disputes Redressal Commission
D. Ajay Kumar, vs United India Insurance Company Ltd. on 30 July, 2012
BEFORE THE A.P STATE CONSUMER DISPUTES REDRESSAL COMMISSION AT HYDERABAD. FA 44 of 2010 against C.C. 128 of 2007, Dist. Forum, Nellore Between: D. Ajay Kumar, Flat No. 101, Sri Sai Residency 10th Cross Road, Magunta Layout Nellore. *** Appellant/ . Complainant And 1) The Branch Manager United India Insurance Company Ltd. Dargamitta Branch, Nellore 2) The Regional Manager United India Insurance Company Ltd. Regional Office, Daba Gardens Visakapatnam. *** Respondents/ O.Ps Counsel for the Appellant: M/s. K. Visweswara Rao Counsel for the Respondents: M/s. E. Venugopal Reddy CORAM: HONBLE SRI JUSTICE D. APPA RAO, PRESIDENT SMT. M. SHREESHA, MEMBER & SRI S. BHUJANGA RAO, MEMBER MONDAY, THIS THE THIRTIETH DAY OF JULY TWO THOUSAND TWELVE ORAL ORDER:
(Per Honble Sri Justice D. Appa Rao, President) ***
1) The complainant preferred this appeal against partly disallowing the claim towards investigation charges and other charges.
2) The case of the complainant in brief is that he took medi-guard policy from the respondent insurance company from the year 2003 and has been paying the premia for all these years. While so, he suffered from ulcer, and had taken treatment from 4.1.2007 to 8.6.2007 in various hospitals. While so, on 4.1.2007 he was admitted in Siddu Nursing Home, Nellore and was discharged on 9.1.2007. He had taken treatment by spending Rs. 6,291.50 ps. in the said hospital. Later he was again admitted in Dr. Raghuram Orthopaedic & Physiotherapy Centre, Nellore where a sum of Rs. 15,812/- was spent for treatment. He was directed to take treatment for diabetes in M.V. Hospital at Chennai. He was admitted on 24.2.2077 and was discharged on 7.3.2007. He had spent Rs. 52,366.70. He underwent various tests as per the advice of the hospital authorities. However, when claims were made the insurance company allowed the claims for Rs. 4,450/-, Rs. 10,667/- and Rs. 32,887/- respectively. He filed the complaint for payment of Rs. 1,03,129.20ps with interest from 9.3.2007 till the date of payment together with compensation of Rs. 1 lakh and costs of Rs. 5,000/-.
3) The insurance company resisted the case. While admitting issuance of medi-guard policy it contended that bonus of 5% was paid on the previous policy dt.
6.3.2006. For the bills submitted for hospitalization in Siddu Nursing Home, Nellore a sum of Rs. 340/- towards miscellaneous charges and Rs. 1,500/- towards hospital charges were disallowed as they were not covered under the policy. The complainant has refused to receive the said amount though an amount of Rs. 4,451.37 was sanctioned as against claim of Rs. 6,291.50.
With regard to second claim it was settled for a sum of Rs. 10,667/- as against Rs. 15,800/ since he submitted the bills and lab reports without any prescriptions from a competent medical practitioner. He got himself conducted several tests on his own.
With regard to third claim a sum of Rs. 33,050/- was settled as against Rs. 52,366.70 as the complainant underwent tests three to four times in a day un-necessarily, and that Doppler study, ECG and other investigations which were not required.
With regard to fourth claim for Rs. 28,659/-
towards treatment charges at Nellore Hospital for the period from 17.5.2007 till 19.5.2007, the claim was not intimated within stipulated time. As per condition No. 5.3 of the policy upon happening of any event which may give raise to a claim under the policy, notice with full particulars shall be sent to the insurance company within 7 days from the date of hospitalization or 30 days from the date of discharge from the hospital. While he was discharged on 19.5.2007 the claim was submitted on 5.9.2007. Some of the amounts were not allowed as they did not cover under the policy. The amounts that were sanctioned was as per the conditions of the policy, and therefore prayed for dismissal of the complaint with costs.
4) The complainant in proof of his case filed his affidavit evidence and got Exs. A1 to A35 marked while the insurance company filed the affidavit evidence of its Divisional Manager and got Exs. B1 to B22 marked.
5) The Dist. Forum after considering the evidence placed on record opined that a sum of Rs. 76,827. 37 ps could be awarded as against the claim for Rs. 1,03,129/- with interest @ 9% p.a., from 9.3.2007 till the date of realization together with costs of Rs. 2,000/-.
6) Aggrieved by the said order, the complainant preferred the appeal contending that the Dist. Forum did not appreciate either facts or law in correct perspective. It ought not have justified deduction of certain amounts by the insurance company. The report of Dr. S. Sudharshan was invented for the purpose of repudiating the claim. Deducting these amounts on an erroneous report of some un-authorised doctor is bad under law, and therefore prayed that the entire claim be allowed.
7) The point that arises for consideration is whether the order of the Dist. Forum is vitiated by mis-appreciation of fact or law?
8) It is not in dispute that the complainant had taken medi-guard policy from the respondent insurance company for the period from 7.3.2007 to 6.3.2008 for a sum of Rs. 1 lakh vide Ex. A1. During the said period he was hospitalized on four occasions. The claims are as follows:
S.No. Name of the Hospital claimed Approved amount Amount 1 Dr. P. Kripanidhi 6291 4450 Sindhu Nursing Home, Nellore 2 Dr. M. Raghuramaiah 15812 10667 Raghuram Orthopedic & Physiotherapy Centre, Nellore 3 MV Hospital for Diabetes (P) Ltd.
52366 32887 Chennai Total 74469 48004 From the above, it is clear that the dispute pertains to a sum of Rs. 26,931/-. The insurance company did not prefer any appeal against the order of the Dist. Forum in awarding Rs. 76,827/-.
9) In the circumstances, the question that arises for consideration is whether the complainant is entitled to the entire amount claimed by him?
In regard to 1st claim as against claim of Rs. 6,291/- the claim was allowed for Rs. 3,821/- rejecting the claim for Rs. 2,470/-.
In regard to 2nd claim as against claim of Rs. 15,812/- the claim was allowed for Rs. 10,667/- rejecting the claim for Rs. 5,145/-.
In regard to 3rd claim as against claim of Rs. 52,366/-
the claim was allowed for Rs. 33,050/- rejecting the claim for Rs. 19,316/-.
10) It may be stated herein that the insurance company while disallowing certain amounts which we have mentioned above, based it on the report of one Dr. S. Sudharshan, who was of the opinion that most of the investigations were repeated or duplicate for mild DBT. Variations of blood sugar would not allow the doctors to conduct repeated tests. Evidently he is not a diabetalogist. The complainant took treatment from M.V. Hospital for Diabetes P. Ltd., The insurance company ought to have taken the opinion from the said doctors and find out whether tests were necessary or not instead of taking the opinion of Dr. S. Sudhershan. The opinion expressed in the certificate is general in nature not specific to the complainants case. It is common that in cases of this nature the doctors would repeat investigations either to obtain second opinion or to monitor his condition in order to administer medicines. The tests were conducted at Care Laboratory & Medical Services, when referred by specialist doctors. We reiterate that the investigator did not examine any of the doctors from whom the complainant had taken treatment. Had they been examined it could have been known whether the tests that were conducted on the complainant are needed, and whether they were only made in order to claim the amounts from the insurance company.
11) It is unfortunate that the insurance company, on one ground or the other is repudiating the amounts despite the fact that policy is taken for medi-claim so that in case of necessity it would be of help to him.
The very purpose for which these policies are taken is to meet the expenditure that could be incurred in cases of emergency. The very purpose of taking medi-claim policies are defeated by refuting these very small amounts. It shows the attitude of the insurance company. When it comes to recovery of premium, and in case of delay even by one day they would repudiate on the ground that the policy was lapsed. However, when claims were to be settled they would make un-reasonable deductions, even though the amount was very small.
12) A perusal of memo filed by the insurance company shows that an amount Rs. 1,840/- in respect of first claim, Rs. 5,145/- in respect of 2nd claim and Rs. 12,540.- in respect of third claim was disallowed. We do not see any rational in rejecting the claims, more so, on the certificate issued by non-treating doctor. This is unjust. We are of the opinion that the complainant is entitled to the amount which he had spent towards treatment. We may also state that the complainant had filed voluminous documentary evidence viz., bills, prescriptions, laboratory reports, investigation charges for Colour Doppler, ECG etc., vide Ex. A17 to A33. Therefore denying the claim basing on the report of Dr. Sudhershan a non-treating doctor in the face of prescriptions of doctors who treated him cannot be up held. The complainant obviously having taken the policy was keeping all these prescriptions, investigation reports and bills etc. so that he could recover the amount from the insurance company, he being an insured. Therefore, we are of the opinion that the complainant is entitled to Rs.
26,931/- the amount denied to the complainant by the insurance company.
13) In the result the appeal is allowed directing the insurance company to pay balance of Rs. 26,931/- besides the amount that was awarded by the Dist. Forum with interest @ 9% p.a., from 9.3.2007 till the date of payment together with costs of Rs. 3,000/- in the appeal. Time for compliance four weeks.
1) _______________________________ PRESIDENT
2) ________________________________ MEMBER
3) _______________________________ MEMBER 30/07/2012 *pnr UP LOAD O.K.