BEFORE THE TELANGANA STATE CONSUMER DISPUTES REDRESSAL COMMISSION : HYDERABAD.

F.A.No. 803 OF 2020 AGAINST ORDERS IN C.C.7/2017 DISTRICT CONSUMER COMMISSION, KARIMNAGAR Between:

1. M/s National Insurance Company Limited, Rep. by its Manager, H.No.2-3-184, Sadguri Arcade Bus Stand to Kaman Road, Karimnagar.

2. M/s MD India Health Care Services (P) Ltd., Rep. by its Authorized Signatory, S.No.46/1, E Space, A2 Building, 3rd floor, Pune Nagar Road, Vidgaonsheri, Pune-411 014.

………..Appellants/ Opposite Parties And:

Rachakonda Pruthvidhar, S/o Ramchander, Age 62 years, Occ. Business, R/o H.No.1-4-226, Jawahar Road, Jagtial Dist. T.S.

……..Respondent/Complainant Counsel for the Appellants/Opposite Parties : M/s. G. Koteswara Rao Counsel for the Respondent/Complainant : M/s. P. Raja Sripathi Rao QUORUM :

HON’BLE SMT. MEENA RAMANATHAN, I/c PRESIDENT &

HON’BLE SRI. V.V.SESHUBABU, MEMBER – (JUDICIAL)

TUESDAY, THE 16th DAY OF SEPTEMBER TWO THOUSAND TWENTY FIVE **********

Order : PER HON’BLE SRI. V.V.SESHUBABU, MEMBER – JUDICIAL

1. The appeal is filed U/s 41 of Consumer Protection Act, 2019 by the Opposite Parties No.1 & 2, aggrieved by the order dated 16.06.2020 in CC No. 7/2017 by the District Consumer Commission, Karimnagar, where under the opposite parties were directed to pay Rs.43,000/- with interest at 9% per annum from

09.01.2007 till realization besides costs of Rs.5,000/- within one month from the date of receipt of the order.

2. The brief averments of the complaint are that the complainant obtained medi-claim insurance from the opposite parties covering the risk for himself and his wife R.Saroja and son R.Pranith and the risk commenced from 09.02.2016 to 08.02.2017; that during the subsistence of risk, Smt. Saroja fell sick and was treated in Omega Hospitals and died on 21.09.2016; that the hospital authorities have charged Rs.2,40,000/-, but the opposite parties paid only Rs.1,97,000/-; that despite several requests, the balance of Rs.43,000/- was not paid. Hence, the complaint.

3. The counter of Opposite Party No.1 is that the complaint is not maintainable either on facts or under law; that the complainant is put to strict of all the averments made in the complaint, except those that are admitted; that there is no deficiency of service at all on the part of the opposite parties; that the claim was settled for Rs.1,97,000/- against Rs.2,40,000/- as per the terms and conditions of the policy; that the terms and conditions goes to show that “room rent, boarding, nursing expenses provided in the hospital are to be dealt with on percentage basis with over all limit of 25% on the sum insured; as per the Head B- relating to the fee of surgeon, anesthetist, Medical Practitioner etc., the maximum limit per ill-ness is 25% on the sum insured; Head-C Anesthesia, Blood, Oxygen, OT Charges, Surgical Appliances, medicines etc., are to the extent of 50% on the sum insured; that by considering those heads only, the amount was paid; that to make a wrongful gain, the complaint is filed, therefore requested to dismiss the complaint with costs.

4. Before the Commission below, complainant filed evidence affidavit as PW1 and marked Ex.A1 to A3. One Smt.D.Geetha Devi, Deputy Manager of opposite party No.1 filed evidence affidavit and got marked Ex.B1 & B2.

5. The Commission below, settled the following points for discussion viz..:

 Whether there is any deficiency in service on the part of Opposite Parties, if so, to what relief the complainant is entitled?

6. Having heard both sides, the Commission below allowed the complaint as stated supra.

Aggrieved by the same, the present appeal is filed by the opposite parties with the following grounds:

 The order of the Commission below is contrary to law, weight of evidence and probabilities of the case.

 The Commission below without observing the terms and conditions of the policy passed the order which is not sustainable under law.

 The Commission below failed to examine the amounts that are to be paid as incorporated in t