BEFORE THE DAKSHINA KANNADA DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, MANGALORE
Dated this the 31st MAY 2017
PRESENT
SRI VISHWESHWARA BHAT D : HON’BLE PRESIDENT
SMT. LAVANYA M. RAI : HON’BLE MEMBER
ORDERS IN
C.C.No.432/2015
(Admitted on 15.12.2015)
Mr. Ramesh,
S/o Late Shankara,
Aged about 35 years,
R/at Bangeradka House,
Shibaje Village & Post,
Belthangady Taluk,
….. COMPLAINANT
(Advocate for the Complainant: Sri SD)
VERSUS
1. Divisional Manager,
Oriental Insurance Company Ltd.
Beauty Plaza, Balmatta Road,
Mangalore, D.K 01.
2. Director,
Shree Kshethra Dharmasthala,
Gramabivriddi Yojane,
Sampoorna Suraksha Programme,
Dharmasthala,
Belthangady Taluk, D.K.
…....OPPOSITE PARTIES
(Advocate for the Opposite Parties No.1 & No.2: Sri UKS)
ORDER DELIVERED BY HON’BLE PRESIDENT
SRI VISHWESHWARA BHAT D:
The above complaint filed under Section 12 of the Consumer Protection Act by the complainant against opposite parties alleging deficiency in service claiming certain reliefs.
The brief facts of the case are as under:
The complainant claims himself with three family members are members of opposite party No.2 medical scheme Sampoorna Suraksha Yojane as per membership No. BLT115341 for the period from 01.04.2014 to 31.03.2015 and paid premium of Rs.1,520/ under which complainant is entitled for a reimbursement of medical expenses of sum of Rs.40,000/ the policy terms and condition was not served on the complainant. Complainants father Shankara who was admitted to Dhanvanthari Hospital Puttur on 12.11.2014 for Laparotomy and Distal Radical Gastrectomy operation and he had discharged on 27.11.2014 and spent Rs.1,30,985 for the treatment. To the notice sent on behalf of complainant’s father opposite parties have not replied. The membership receipt issued by opposite party No.2 is against law and it has no details of insurance and it is not an insurance company and TPA at all. As required by IRDA opposite party No.1 is duty bound to pay the claim amount. The business carried out by opposite party No.2 the insurance issuance of receipt is illegal. Opposite party No.2 has paid only Rs.37,000/ to complainant by way of cheque. Hence seeks direction for payment against opposite parties.
2. Opposite party No.1 in the version mentions opposite party No.2 in the name of SKDRDP under the Universal Health Scheme was issued with group insurance policy by opposite party No.1 based on this the member of 2nd opposite party of the insurance are covered subject to the terms and condition of Universal Health Scheme. The person covered under Sampoorna Suraksha Yojane by Sumathi, Sankara, Ramesh and prashanth are the members are entitled for a reimbursement of medical expenses to the extent of Rs.40,000/ only of which Rs.3,000 was claimed and paid earlier for Ashwinin Hospital Puttur for medical reimbursement and the terms of the policy under Universal Health Scheme the balance amount of Rs.37,000 was paid to the complainant. As such seek dismissal of the complaint.
3. Opposite party No.2 also filed version disputing allegation alleged and that opposite party No.2 obtained group insurance from opposite party No.1 covering the risk of his members. The insurance coverage under the policy obtained to his member as sated by opposite party No.1 is under the coverage of the said Sampoorna Suraksha Yojane to complainant and is admitted opposite party No.1 has already pay Rs. 3,000 towards medical expenses and another balance of Rs.37,000/ was also paid to the claim made by complainant and the entire claim amount of Rs.40,000 towards reimbursement of medical expense upto the extent for which complainant eligible and complainant is not entitle for any amount and hence seeks dismissal of the complaint.
4. In support of the above complaint Mr. Ramesh filed affidavit evidence as CW1 and answered to the interrogatories served on him and produced documents got marked at Ex.C1 to C9 and Ex.A1 as detailed in the annexure here below. On behalf of the opposite parties Mr. Abraham M.K (RW1) Director, Sampoorna Suraksha Yojane, also filed affidavit evidence and Mr. Raghu Naik (RW2) Assistant Manager, Oriental Insurance Company, Mangalore also filed affidavit evidence and answered to the interrogatories served on them and produce documents got marked at Ex.R1 as detailed in the annexure here below.
5. In view of the above said facts, the points for consideration in the case are:
- Whether the Complainant is a consumer and the dispute between the parties?
- If so, whether the Complainant is entitled for any of the reliefs claimed?
- What order?
The learned counsels for both sides filed notes of arguments. We have considered entire case filed on record including evidence tendered by parties. Our findings on the points are as under follows:
Point No. (i) : Affirmative
Point No. (ii) : Negative
Point No. (iii) : As per the final order.
REASONS
6. POINTS No. (i) & (ii): That the risk of complainant family Sumathi, Sankara, Ramesh and Prashanth as mentioned in the membership details and condition book produced by opposite party under the Sampoorna Suraksha Yojane 2014.15 is not disputed by opposite party and this group insurance coverage was issued by opposite party No.1 to the member of opposite party No.2 is also admitted. Hence there is relationship of consumer and service provider between the parties
7. As seen from the details of the members and condition of the book produced in this case mentions that the upper limit to the said family of sumathi and three other member of the family of complainant is shown as Rs.40000/
8. At para 9 of the complaint the complainant acknowledges payment of Rs.37,000 by opposite party No.2 by way of cheque bearing No. 831753 dated 5.10.2015 drawn on Vijaya Bank Belthangady Branch in the respect of Rs.3,000 paid is admitted in his answer to the interrogatories to the question No. 22 of opposite party No.2 as well as question No. 24 posed on behalf of opposite party to complainant reads thus:
22. Do you admit that opposite party No.2 is obtaining a group insurance policy covering its members who opt for the Sampoorna Suraksha Scheme?
Ans: I say such information not furnished to me
24. Do you admit that opposite party has earlier paid a sum of Rs.3,000/ for the medical treatment availed at Ashwini Hospital Puttur towards medical reimbursement in respect of the treatment to Mrs. Sumathi?
Ans: I say yes.
Thus the receipt of entire amount of Rs.40,000/- as per promise undertaken by opposite party No.1 has paid over to complainant.
9. Learned counsel for complainant to buttress his argument referred to a reported case National Consumer Disputes Redressal Commission, New Delhi in III (2007) CPJ 34 (NC) National Insurance Co. Ltd vs D.P. Jain in this reported case insurance of mobile phone stolen the claim was the ground for repudiation made was absence of actual or threatened force and such circumstance in the liability to reimburse complainant.
10. Reference was also made by learned counsel for complainant to National Consumer Disputes Redressal Commission, New Delhi in United India Insurance Co Ltd & Anr vs S.M.S Tele Communications & Anr III (2009) CPJ 246 (NC) in this reported case it was held when the exclusion clause is not explained it has to be ignored.
11. Even in National Consumer Disputes Redressal Commission, New Delhi in Mahesh Chandu Ghiya vs New India Assurance Co. ltd I (2011) CPJ 25 (NC) mention that the restriction in exclusion clause in the policy was a unilateral action and no document is placed to justify the Corporation’s action and the complainant not told about such clause under such circumstance it was held the insurance company is liable.
12. In National Consumer Disputes Redressal Commission, New Delhi United India Insurance Co Ltd vs Dinaz Vervatwala & Anr IV (2015) CPJ 376 (NC) wherein it is held there is no evidence that opposite parties ever supplied terms and conditions of the group personal accident policy exercise of unfair trade practice proved and wherein under such circumstance payment of expenses was ordered.
13. Referring to these reported cases it was argued for complainant there was nothing to show the terms and conditions of the restrictions of the claims of Rs.40,000/ was brought to the notice of complainant and other family members.
14. The complainant along with the complaint produced the membership receipt issued to him by opposite party surprising this document was not got marked by complainant. As seen from this document it is now marked for the sake of convenience as Ex.A1. There is specific mention as to what is the amount covered for claim of medical reimbursement under the said policy. In fact the scanned copy of Ex.A1 is as follows:
Thus on going through this Ex.A1 produced by complainant specifically mentioned the limitation fixed to the family of complainant as Rs.40,000 that amount was already been paid to complainant as acknowledged by him even in the complaint itself. Hence the complainant cannot take shelter of non-disclosure of the terms and condition of the issue of the policy.
15. As such the law laid down relied upon by learned counsel for complainant in the reported case laws is of no help to the complainant. As such there is no lies between the parties as complainant himself admitted payment of Rs.40,000/ in the complaint itself. Hence the claim of non disclosure of the conditions also falls to the ground. Hence we answer points No.1 in the affirmative and No.2 against the complainant.
POINTS No. (iii): Wherefore the following
ORDER
The complaint is dismissed.
Copy of this order as per statutory requirements, be forwarded to the parties free of cost and file shall be consigned to record room.
(Page No.1 to 9 directly typed by steno on computer system to the dictation of President revised and pronounced in the open court on this the 31st May 2017)
MEMBER PRESIDENT
(LAVANYA M. RAI) (VISHWESHWARA BHAT D)
D.K. District Consumer Forum D.K. District Consumer Forum
Mangalore Mangalore
ANNEXURE
Witnesses examined on behalf of the Complainants:
CW1 Mr. Ramesh
Documents marked on behalf of the Complainants:
Ex.C1: 01.04.2014: Copy of the membership receipt for the Year 2014.15
Ex.C2: 15.12.2014: Copy of the claim letter
Ex.C3: 27.11.2014: Copies of the Bills (47)
Ex.C4: 27.11.2014: Copy of the Discharge Summary
Ex.C5: 14.03.2015: O/c of the Lawyer Notice
Ex.C6: 17.03.2015: Postal Acknowledgment of 2nd OP
Ex.C7: 18.06.2015: O/c of the Lawyer Notice
Ex.C8: 19.06.2015: Postal Acknowledgement (2)
Ex.C9: 29.10.2015: Copy of the Death Certificate
Witnesses examined on behalf of the Opposite Parties:
RW1 Mr. Abraham M.K, Director, Sampoorna Suraksha Yojane
RW2 Mr. Raghu Naik Assistant Manager, Oriental Insurance Company, Mangalore
Documents marked on behalf of the Opposite Parties:
Ex.R1: True copy of the Policy
Dated: 31.05.2017 PRESIDENT
