BEFORE THE DAKSHINA KANNADA DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, MANGALORE

Dated this the 29^th FEBRUARY 2016

PRESENT

SMT. ASHA SHETTY             :   HON’BLE PRESIDENT

             SMT.LAVANYA M. RAI          :   HON’BLE MEMBER

COMPLAINT NO.430/2014

(Admitted on 15.11.2014)

Smt. Vasanthi

W/o. Balakrishna Prabhu,

Aged about 45 years,

R/at. Darandakukku House,

Kodimbadi Village, and Post,

Puttur Taluk, D.K.                                               …….. COMPLAINANT

(Advocate for Complainant: Sri. Sanjaya D)

          VERSUS

1. The Manager,

United India Insurance Company Ltd,

Ram Bhavana Complex,

Kodialbai,

Mangalore, D.K. 01

2. Director

Shree Kshethra Dharmasthala,

Gramabivriddi Yojane,

Sampoorna Suraksha Programme,

Dharmasthala,

Belthangady Taluk. D.K.                    ……OPPOSITE PARTIES

(Advocate for Opposite Party No 1. : Sri. M.V. Shanker Bhat)

(Advocate for Opposite Party No 2. : Sri. Udaya Kumar Shetty)

ORDER DELIVERED BY HON’BLE PRESIDENT

SMT. ASHA SHETTY:

I.       1. This complaint is filed under Section 12 of the Consumer Protection Act alleging deficiency in service as against the Opposite Parties claiming certain reliefs. 

The brief facts of the case are as under:

          The complainant along with 4 family members are the member of the 2^nd Opposite Party medical insurance scheme in Sampoorna Suraksha Yojane as per membership No. PUT 3144209.  The sum assured under the scheme was of Rs. 50,000/-.   It is stated that the complainant’s husband Balakrishna Prabhu was admitted to Dhanvanthari hospital Puttur on 3.11.2013 for gross anemia, mass per abdomen and generalized tenderness with fever and discharged on 12.11.2013 spent Rs. 34,655 for the operation.  It is stated that the Opposite Parties not reimbursed the medical expenses and the membership receipt issued by the 2^nd Opposite Party has no detail about insurance and insurance company nor any terms and conditions.  It is further stated that, the 2^nd Opposite Party cannot instruct a scheme member to go to a particular hospital.  There is no condition imposed by the 1s Opposite Party, further they submitted that the amount involved in the claim is a meager amount of Rs. 34,655/- not honoring the claim till this date amounts to deficiency in service  and hence the complainant filed the above complaint under Section 12 of the Consumer Protection Act 1986 (herein after referred to as ‘the Act’) seeking direction from this Forum to the Opposite Parties to pay a sum of Rs.34,655/- including 12% interest from 12.11.2013 till the payment along with compensation and cost of the proceedings.

II.      1. Version notice served to the Opposite Parties and the Opposite Parties appeared through their counsels filed version.  It is stated that the hospitalization of husband of the complainant is not known to this Opposite Party.  Further stated that as per the scheme the complainant had to submit the documents to 2^nd Opposite Party and after it is closed by them the 2^nd Opposite Party will pay.   The benefit of policy can be availed only if requirements of the scheme are fulfilled and denied the deficiency in service sought for dismissal of the complaint.

The 2^nd Opposite Party stated that, Samporna Surkasha scheme is unique program wherein interested participant join together to bring security to their insurance/life during ailment/accidents. It is stated that SKDRDP self help group has formulated a scheme whereby large number of people who are members of Yojana covered under group mediclaim insurance.  This Opposite Party not working for any profits.  The complainant is fully aware of the scheme and the copy of Mahiti Patra which given information regarding the procedures of SKDRDP.  The Opposite Party has issued membership Card along with Mahiti Patra.  It is stated that member has to submit application from and bills relevant medical record to the 1^st Opposite Party.  On verification of documents, it is found that some of the documents are mismatched and requested comply the formalities but it was not complied.  The complainant not submitted the claim.  Since the complainant not abide by the terms and conditions of the said scheme and not followed the procedure, she is not entitled for the claim and denied the deficiency of service.

III.     1.  In support of the complaint, Sri Vasanthi (CW1) – Complainant filed affidavit reiterating what has been stated in the complaint and answered the interrogatories served on her and produced Ex. C1 to C10. 

          In view of the above said facts, the points now that arise for our consideration in this case are as under:

1. Whether the Complainant proves that the Opposite Parties have committed deficiency in service?

2. If so, whether the Complainant is entitled for the reliefs claimed?

3. 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) & (iii): As per the final order.       

REASONS

IV.     1.  POINTS NO. (i) TO (iii):

In the present case the point which are not in dispute is that the complainant is insured with 1^st Opposite Party under the group insurance policy bearing No. 070800/48/13/41/00 000119.  It is also not in dispute that the complainant husband one Mr. Balakrishna Prabhu admitted to Dhanvantari hospital on 03.11.2013 for ailments and discharged on 12.11.2013.

Now the point are in dispute between the parties is that the complainant contended that under the insurance policy she has filed claim along with the original discharge summary and medical bills and reports but Opposite Party not honored the claim till this date.

On the other hand Opposite Parties contended that the complainant sent the documents directly to first Opposite Party.  As per this scheme complainant has to submit the insurance claim to second Opposite Party.  In fact there is no deficiency and complainant was asked to comply certain documents but she has not done.

On perusal of the oral as well as documentary evidence it is understood that the complainant and her family was covered under the insurance policy bearing policy No. 070800/48/13/41/00000119 as per exhibit C-2.  Now the point for consideration is that the role of second Opposite Party is very limited because it is an NGO cannot act as a insurance company.  The second Opposite Party of course rendering service by collecting insurance premium and paying it to the insurance company. In the instant case the second Opposite Party collected the premium and paid it to the insurance company.  There is no dispute what so ever the scheme is between the insurance companies i.e. 1^st opposite party with the complainant the construct between second Opposite Party i.e. NGO with the insurance company is nothing to do with the insured herein the complainant.  There is no contract between the 2^nd opposite party and the complainant as far as medical reimbursements is concerned. In the instant case the complainant sent all the original bills directly to the 1^st opposite party. Just because the complainant not sent the documents to the 2^nd opposite party, the insurance company cannot treat the claim arbitrarily on the other hand the 1^st opposite party should have forwarded the documents to the 2^nd opposite party instead of repudiating the claim randomly. Further the 1^st opposite party cannot impose condition “that you go to a particular hospital etc., etc.,” it is the primary duty of the insurance company to furnish the copy of the policy along with terms and conditions to execute the insurance policy.  But in the instant case the first Opposite Party cannot impose a condition that you go to a particular hospital etc., Since the first Opposite Party not considered the claim till this date it amounts to deficiency in service as well as unfair trade practice.

Under the above circumstances, we hereby directed the Opposite Party No. 1 to pay Rs. 34,000/- along with interest @ 12% p.a. from the date of complaint till the date of payment and also pay Rs. 3,000/- as cost of litigation expenses. Payment shall be made within 30 days from the date of this order.  Complaint against opposite party No. 1 is dismissed as there is no contractual relationship between them.

          In the result, we pass the following:        

ORDER

The complaint is allowed, opposite party No. 1 shall pay Rs. 34,000/- along with interest @ 12% p.a. from the date of complaint till the date of payment and also pay Rs. 3,000/- as cost of litigation expenses. Payment shall be made within 30 days from the date of receipt of this order.

Copy of this order as per statutory requirements, be forward to the parties and file shall be consigned to record room.

(Page No.1 to 7 dictated to the Stenographer typed by him, revised and pronounced in the open court on this the 29^th day of FEBRUARY- 2016).

PRESIDENT                               MEMBER

 (SMT. ASHA SHETTY)                 (SMT. LAVANYA M.RAI)

D.K. District Consumer Forum            D.K. District Consumer Forum

     Mangalore.                                    Mangalore.     

ANNEXURE

Witnesses examined on behalf of the Complainant:

CW1 – Vasanthi               – Complainant.

Documents produced on behalf of the Complainant:

Ex C1: 01.04.2013: Copy of the membership receipt

     for the year 2013-14.

Ex C2: 25.07.2013: Copy of the claim letter.

Ex C3: 02.08.2013: Reply of the Opposite Party.

Ex C4: 23.07.2013: Copy of the discharge summary.

Ex C5: 23.07.2013: Copies of the bills (6).

Ex C6: 21.09.2013: O/C of the regd lawyer’s notice.

Ex C7: 25.09.2013: Reply of the 2^nd opposite Party.

Ex C8: 21.11.2013: O/C of the regd lawyer’s notice.

Ex C9: 02.12.2013: Reply of the 1^st opposite Party.

ExC10: 22.11.2013: Postal acknowledgment of 2^nd Opposite Party.

Witnesses examined on behalf of the Opposite Parties:

RW-1: Amar Kumar Sinha, of  Opposite Party No.1  and

RW-2: Mr. Abraham M.K. Director, Sampoorna Suraksha, SKDRDP(R) Dharmastala.

Documents produced on behalf of the Opposite Parties:    

Ex-R-1: Copy of the Mahithi Patra.

Dated:29-02-2016                          PRESIDENT