BEFORE THE DAKSHINA KANNADA DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, ADDITIONAL BENCH, MANGALORE
Dated this the 15th December 2016
PRESENT
SRI. VISHWESHWARA BHAT D : HON’BLE PRESIDENT
SRI. T.C. RAJASHEKAR : HON’BLE MEMBER
ORDER IN
C.C.No.485/2014
(Admitted on 10.12.2014)
Smt. Girija,
W/o Babu,
Aged about 50 years,
R/at Manjalthadka House,
Madnoor Village and Post,
Puttur Tq.
….. COMPLAINANT
(Advocate for the Complainant: Sri. SD)
VERSUS
1. The Manager,
United India Insurance Company Ltd.,
Divisional Office, Rambhavan Complex,
Kodialbail, Mangalore, D.K 03.
2. Director,
Shree Kshethra Dharmasthala,
Gramabivriddi Yojane,
Sampoorna Suraksha Programme,
Dharmasthala,
Belthangady Taluk, D.K.
......OPPOSITE PARTIES
(Advocate for the Opposite Part No.1: Sri. MVSB)
(Advocate for the Opposite Part No.2: Sri. UKS)
ORDER DELIVERED BY HON’BLE PRESIDENT
SRI. VISHWESHWARA BHAT D:
I. 1. The above complaint filed under Section 12 of the Consumer Protection Act alleging deficiency in service against claiming certain reliefs.
The brief facts of the case are as under:
The complainant contends that she along with four family members are members of opposite party No.2’s medical insurance scheme Sampoorna Suraksha Yojane under membership No.3469299 for period from 1.4.2013 and paid Rs.1,900/. As premium which entitled reimbursement of medical expenses of Rs.50,000/ as per information of opposite party No.2 by letter dated 28.1.2014. The complainant insured with opposite party No.1 and their insure policy No.070800/48/13/41/00000119. From 11.01.2014 the complainant had taken treatment for as inpatient at Dhanvanthari Hospiral Puttur for high fever and spent Rs.10,170/. Opposite party No.2 furnished details of the insurance policy and when the claim was filed before opposite party No.1 on 14.2.2014 it was not replied.
2. The complainant claims the membership issued by opposite party No.2 is against law. And it as no details of insurance and insurance company and receipt issued by opposite party No.2 is void. Opposite party No.1 has not issued the policy of the terms and conditions to the complainant. It is also claimed the member of the Shree Kshethra Dharmasthala Gramabivriddi Yojane (for short SKDGY). SKDGY has to be a member of Sampoorna Suraksha Yojane scheme and they cannot compel the member to take treatment in a particular hospital. She further contends the opposite parties had not followed the law while issuing membership receipt are duty bound to issue membership receipt as specified by the law the non issuance of membership receipt as per law amounts to deficiency in service. Second opposite party has no right to issue membership receipt in their name. Hence seeks compensation as detailed.
II. Opposite party No.1 in the written version dispute all the allegations made in the complaint and its liability. As per the scheme the complainant had to submit the document with opposite party No.2 and after it is cleared by them opposite party No.1 would pay the amount which is payable as per entitlement. Instead of returning the paper to the complainants opposite party No.1 wrote to complainant to furnish particular by a registered legal notice dated 2.6.2014. When the complainant voluntarily joined to opposite party No.2 which is void act to her own case there is no deficiency of service as there is no relationship in existence, in view of void transactions. There is a common processing to a member alone with complainant. The complainant has refused to submit document to second opposite party and the benefit can be avail only on fulfilment of this condition. The complainant having not furnished the bills to opposite party No.2, as per letter dated 2.6.2014 is not entitled for the claims.
2. Opposite party No.2 contends insurance of membership mentioned in the complaint was given to the complainant with first opposite party. The entire program in respect of the group insurance is by Shree Kshethra Dharmasthala Gramabivriddi Yojane self help group participation subject to voluntary payment of the fee. The complainant is bound by the terms and conditions of the scheme. The complainant is fully aware of the scheme under Sampoorna Suraksha Yojane hospitals are also listed in the Mahithi Patra. The member ship card is issued for the purpose of identity for the member only. The complainant has directly sent the medical bills to opposite party No.1. At the time of becoming member of the group the complainant was made known of the norms. Opposite party No.2 is only entitled to issue the membership receipt who voluntarily after the insurance coverage. Name of the scheme is reimbursement the medical expences but it is only for those diseases which are covered but not all the diseases subject to receipt availability. The list of diseases not covered are mentioned in the Mahithi Patra. Contending there is no deficiency in service seeks dismissal of the complaint.
3. In support of the above complainant Smt. Girija filed affidavit evidence as CW1 and answered the interrogatories served on her and produced documents marked Ex.C1 to C7. On behalf of the opposite party Mr.Amar Kumar Sinha (RW1) Sr. Division Manager also filed affidavit evidence and answered the interrogatories served on him.
III. 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 other reliefs claimed?
- What order?
We have considered the notes/oral arguments submitted by the learned counsels and also considered the materials that was placed before this Forum and answer the points are as follows:
Point No. (i): Affirmative
Point No. (ii): Negative
Point No.(iii): As per the final order.
REASONS
IV. POINTS No. (i): In this case the complainant claims she has been member of the medical insurance Sampoorna Suraksha Yojane launched by opposite party No.2 and is entitled for payment of the claim towards medical expences under Sampoorna Suraksha Yojane towards treatment. However the claim of complainant that the group insurance cover was issued by opposite party No.1 and the liability thereon was disputed by opposite party No.1 and there is no direct nexus between complainant and opposite party No.1 as insurance coverage is provided by complainant admittedly by opposite party No.1 to the membership of the group of opposite party No.2 at its instance under group insurance scheme. In the circumstance as liability was disputed there is relationship of consumer and service provider between complainant and opposite parties as complainants did pay the charges to opposite party No.2. Hence we answer point No.1 in the affirmative.
POINTS No.(ii): In this case complainant and her family members are members of the Sampoorna Suraksha Yojane of opposite party No.2 is not disputed by opposite party No.2. Opposite party No.2 did admit to its members group insurance coverage is provided through opposite party No.1 by collecting certain fixed amount from its members. In this case complainant she paid Rs.1,900/ to opposite party No.2 which is not disputed by opposite party No.2. The complainant did produce the medical bills towards the treatment obtained by her.
2. However even according to complainant the acts of opposite party No.2 in the membership receipt issued is against the insurance law and illegal as opposite party No.2 is not authorised to issue coverage under IRDA. Infact it is the specific case of complainant that she laid claim with the bills of medical expences directly with opposite party No.1 without furnishing particulars of the policy particulars when infact the complainant ought to have furnished the bills with opposite party No.2. It is undisputed between opposite party No.1 and opposite party No.2 that opposite party No.2 has to scrutinize and pass the admissibility or otherwise of the claim made by its members like the complainant. That evidently was not done by the complainant. When complainant did not do her part of the duty and instead attacked the acts of opposite party No.1 and No.2 inter see between them. Under the circumstances we are of the view that the complainant has failed to make out the case of deficiency in service on the part of the opponents. This is especially so in complainant directly filling the claim to opposite party No.1 without furnishing those particulars to opposite party No.2 and there by not giving opportunity to opposite party No.2 to consider admissibility of the claim of the complainant. Hence we are of the view complainant failed to prove deficiency in service on the part of the opposite parties. Hence we answer point No.2 in the negative.
POINTS No. (iii): Wherefore the following order
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 7 directly dictated by President to computer system to the Stenographer typed by her, revised and pronounced in the open court on this the 15th December 2016)
MEMBER PRESIDENT
(SRI. T.C. RAJASHEKAR) (SRI. VISHWESHWARA BHAT D)
D.K. District Consumer Forum D.K. District Consumer Forum
Additional Bench, Mangalore Additional Bench, Mangalore
ANNEXURE
Witnesses examined on behalf of the Complainant:
CW1 Smt. Girija
Documents marked on behalf of the Complainant:
Ex.C1: 01.04.2013 : Copy of the membership receipt for the Year 2013.14
Ex.C2: 27.01.2014 : Copy of the letter addressed to 2nd Opposite party
Ex.C3: 28.01.2014 : Reply of the 2nd opposite party with insurance Details
Ex.C4: 14.02.2014 : Copy of the claim letter
Ex.C5: 19.02.2014 : Postal Acknowledgement
Ex.C6: 17.01.2014 : Copy of the discharge summary
Ex.C7:17.01.2014 : Copies of the bills (9)
Witnesses examined on behalf of the Opposite Parties:
RW1 Mr.Amar Kumar Sinha (RW1) Sr. Division Manager
Documents marked on behalf of the Opposite Parties:
Nil
Dated: 15.12.2016 PRESIDENT
