State Consumer Disputes Redressal Commission
The Manager, Ab Arogyadaan vs S.Sampath Reddy S/O Narasimha Reddy And ... on 20 January, 2014
BEFORE A.P STATE CONSUMER DISPUTES REDRESSAL COMMISSION AT HYDERABAD F.A.No.997 OF 2013 AGAINST C.C.NO.53 OF 2012 DISTRICT FORUM NIZAMABAD Between: The Manager, AB Arogyadaan United India Insurance Co.Ltd., Plot No.49, Nagarjuna Hills, Punjagutta, Hyderabad Appellant/opposite party no.1 A N D 1. S.Sampath Reddy S/o Narasimha Reddy Aged: 54 years, Occ: Advocate R/o Nizamabad Respondent/complainant 2. The Manager, Andhra Bank Branch: Hyderabad Road Nizamabad, Nizamabad Dist. Respondent/opposite party no.2 Counsel for the Appellants M/s Ramachandra Reddy Gadi Counsel for the Respondents M/s K.Karam Chander Reddy (R1) Served(R2) QUORUM: SRI R.LAKSHMINARASIMHA RAO, HONBLE MEMBER
SRI THOTA ASHOK KUMAR, HONBLE MEMBER & SRI S.BHUJANGA RAO, HONBLE MEMBER MONDAY THE TWENTIETH DAY OF JANUARY TWO THOUSAND FOURTEEN Oral Order (As per Sri R.Lakshminarasimha Rao, Honble Member) ***
1. The appeal is challenge to the order of the District Forum which granted the relief for balance amount of the expenditure of that was incurred by the respondent for undergoing CABG at Yashoda Hospital, Hyderabad.
2. The respondent obtained Floater Medi Claim policy on 18.09.2008 for sum assured of `5 lakh covering risk on his wife, son and him. The respondent got renewed the policy bearing number 050400/48/11/41/00000225 for three times and for the fourth time from 21.09.2011 to 20.09.2012 for the sum assured of `5,00,000/-. The respondent was admitted at Yashoda Hospital on 11.06.2012 and he had undergone Cardiothoracic Minimal Access Surgery on 16.06.2012 and discharged on 18.06.2012. At the time of his hospitalization, on his request the TPA, third party administrator provided for arrangement of casteless facility to the extent of `1,91,250/- as per agreed PPN Tariff by GIPSA .
3. The respondent incurred expenditure to an extent of `2,97,100/-
for his medical treatment and he claimed for balance amount after deducting the amount of `1,91,250/-
arranged by the TPA to the hospital and later he got issued notice dated 30.07.2012 claiming the amount from the appellant-insurance company.
4. The appellant contended that in terms of the guidelines of PPN Tariff prescribed by GIPSA, the TPA settled the claim and the respondent accepted the amount towards final settlement and without any objection therefor.
5. The District Forum allowed the complaint on the premise of Clause 1.2 of terms of the insurance policy provider for 80% of sum insured for treatment of diseases such as cancer, brain tumour, pacemaker etc.
6. Aggrieved by the order of the District Forum, the opposite party insurance company has filed appeal contending that the award passed by the District Forum is erroneous and as per the agreement PPN tariffs by GIPSA the maximum amount that can be payable towards CABG is `1,91,250/-
and accordingly the TPA has settled the amount. It is contended that the respondent without approaching the appellant or TPA, filed the complaint before the District Forum.
7. The point for consideration is whether the order of the District Forum is vitiated by misappreciation of facts or law?
8. Many of the facts have not been in dispute between the parties such as the respondent obtaining Floater Medi claim policy for his wife, son and him and his hospitalization on 11.06.2012 for undergoing CABG at Yashoda Hospital, Hyderabad and the amount he incurred towards his treatment at Yashoda Hospital. It is also not disputed that the Third Party Administrator settled the claim for cashless facility for `1,91,250/-. The respondent claimed balance amount whereas the appellant refused to accept any further liability on the premise of PPN tariffs by GIPSA the maximum amount that can be payable towards CABG is `1,91,250/-.
9. Sub-clause 5.1 of Clause 4 of the terms of the insurance policy stipulate the liability of the appellant-insurance company to 1% of the sum assured per day or actual amount towards room rent and nursing expenses and 2% of the sum insured towards ICU expenses and 80% of the sum insured subject to `4,00,000/- for specified major surgeries such as cancer, brain tumour pace maker etc.
10. The terms of insurance policy enable the respondent to claim the expenses for surgery pertaining to heart to the extent of 80% of the sum insured subject to maximum amount of `4,00,000/-. Sub Clause 5.1 of Clause 1.2 of the terms of the policy reads as under:
5.1 1. Room rent & Nursing expenses: Not exceeding 1% of the Sum Insured per day or actual amount, whichever is less.
2. ICU Expenses: Not exceeding 2% of the Sum Insured per day or actual amount whoever is less.
3. Hospitalization expenses limited to:
(a) Cataract :10% of SI subject to max of Rs.25,000/-
(b) Hernia :15% of SI subject to max of Rs.30,000/-
(c) Hysteretomy :20% of SI subject to max of Rs.50,000/-
(d) For specified major surgeries :80% of SI subject to Rs.4,00,000/-
Cardiac/Cancer/Brain Tumour/Pace Maker implantation/Hip replacement/|Knee joint replacement.
(e) In respect of persons above 60 years :20% deductible will be applied on all admissible claims.
(f) Pre and post Hospitalization Expenses : Actual subject to a maximum of 10% of the sum insured.
10. The respondent claimed an amount of `2,97,000/- and the appellant had restricted the amount to `1,91,250/-. The contention of the appellant has to be viewed in the light of PPN tariffs by GIPSA the maximum amount. The appellant-insurance company has not been able to show whether GIPSA has legal identity and whether Standard rates for any medical procedures are negotiated for entire City or for Individual hospital or nursing home and the name and/or Designation of persons, who negotiates Standard rates for different medical procedures, GIPSA or TPA and whether GIPSA registered under any Societies Act, Trust Act, or Companies Act or is GIPSA passed in Parliament as also the criteria which is taken into account when standard rates for different medical procedures are fixed and the name of the monitoring agency that governs the working of GIPSA. Therefore, this Commission is inclined to dismiss the appeal.
12. In the result, the appeal is dismissed confirming the order of the District Forum. There shall be no separate order as to costs.
MEMBER MEMBER MEMBER కె.ఎం.కె.* Dt.20.01.2014