BEFORE THE DAKSHINA KANNADA DISTRICT CONSUMER DISPUTES REDRESSAL FORUM,  MANGALORE

Dated this the 31^st  May 2017

PRESENT

  SRI VISHWESHWARA BHAT D     : HON’BLE PRESIDENT

   SMT.LAVANYA M. RAI                   : HON’BLE MEMBER

ORDERS IN

C.C.No.86/2015

           (Admitted on 19.2.2015)           

Bhaskara,

S/o Late. Rukmayya,

R/at Kulsige House,

Kalmadka Village and P.O.

Sullia Tq, D.K.

                                                                 ……… Complainant

(Advocate for Complainant by 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 Opposite Party No.1. Sri. AKK)

 (Advocate for Opposite Party No.2. Sri. UKS)

ORDER DELIVERED BY HON’BLE MEMBER

SMT. LAVANYA M. RAI

1.  This complaint is filed under section 12 of the Consumer Protection Act alleging deficiency in service against the opposite party claiming certain reliefs.

The brief facts of the case are as under:

          The complainant along with 3 family members are the members of 2^nd Opposite Party’s medical insurance scheme Sampoorna Suraksha Yojane as per membership No. SUL56136 for the period from 1.4.2014 to 31.3.2015 by paying of Rs.1,520/ as premium.  Under the medical insurance scheme the complainant is entitled for a reimburse medical expenses of Rs. 40,000/.  As per the information provided by the Opposite Party complainant is insured with the 1^st Opposite Party under group insurance policy.  But policy number and conditions are not served to the complainant and also not given any particulars of the policy. The complainant was admitted to Dhanvanthari Hospital Puttur on 7.7.2014 for fall from motor cycle and after operation the complainant was discharged on 11.7.2014.  The complainant has spent of Rs.36,160/ for the above treatment.  Thereafter the complainant has filed claim letter to the Opposite Party No.1 as per letter dated 13.8.2014 along with copy of membership receipt, originals of discharge summery and bills on 20.8.2014 and the 1^st Opposite Party has replied that the claim document should be made with 2^nd Opposite Party.  Hence the complainant got issued regd lawyers notice to the Opposite Parties but Opposite Parties are not paid the claim amount.  Hence the above complaint filed by the complainant before this forum under section 12 of the C.P.Act 1986(here in after referred to as the Act) seeking direction  to pay Rs.36,160/ to complainant with 12% interest from 11.7.2014 till payment and also pay for a Rs.20,000/ as compensation and to pay Rs.10,000/ as expenses and certain other reliefs.

II. Version Notice served to the opposite parties by RPAD, Opposite Parties filed version. Opposite Party no.1 submits that the scheme as envisaged by the public sector companies with SKDRDP for single person premium is charged at Rs.350/ plus service tax and the benefit of insurance cover would be Rs.10,000/ per person.  The complainant has paid Rs.1,520/ which includes service tax payable, the insurance cover would be for total sum of Rs.40,000/ for four persons and individually it would be Rs.10,000/ as per the procedure, the member has to submit to SKDRDP who process it and forward it to TPA Medi Assist who in turn decides the entitlement of such insured persons claim. With regard to the present claim of the complainant is concerned, it appears that certain requirements mentioned at the stage of processing the claim by Opposite Party No.2 was not furnished by the complainant.  In this regard the Opposite Party No.1 has written a reply dated 16.9.2014 to his letter 13.8.2014, but the complainant did not respond it.  The benefit of policy can be availed only if requirements of the scheme are fulfilled. Without the complainant performing his part of requirement, deficiency in service cannot be alleged by Opposite Party.  Hence the processing of the claim of the complainant is not finalized.  Without all the requirements being furnished, the complainant insists on his claim being accepted. On the other hand Opposite Party No.2 filed version admitted that the Sampoorna Suraksha Scheme is a unique programme wherein interested participants join together to bring security to their insecure life during ailment/accident/hospitalization.  The entire program is designed based on the self-mutual help, wherein interested members of the SKDRDP self help group participate in this program by contributing an annual subscription and a part of the total subscription amount is paid as premium by the SKDRDP to the insurance companies to look after eligible members up to the prefixed amount and to meet the medical treatment expenses during hospitalization in the network hospitals only.  The Opposite Party had entered into such memorandum of understanding with the four nationalized insurance companies to cover the members of the SKDRDP self help group.  In fact the membership No. SUL156136 which has been issued to the complainant is insured the 1^st Opposite Party. It is admitted that the Opposite Party with a view of provide social security to the members of the SKDRDP self help group/ yojana has formulated a scheme whereby large number of people who are the members of Yojana/group be covered under group mediclaim insurance.  This Opposite Party is only registering its self help group members for such benefits.  In fact it is a social service wherein under benevolent scheme they are providing health protection among other benefits to those who subscribed or opted for the said sampoorna suraksha scheme.  The Opposite Party admitted that the complainant being fully aware of the conditions of the Sampoorna Suraksha has become the members of the sampoorna surakasha and the 1^st Opposite Party has issued membership no. SUL156136 to the complainant and the Opposite Party has issued the membership card along with the Niyamavali pustak and the original membership card is in the possession of the complainant hence prays for dismissal.     

III.     In support of the above complaint, the complainant Mr. Bhaskara, filed affidavit evidence as CW1 and answered the interrogatories served on him and produced documents got marked at Ex.C1 to C7. On behalf of the opposite party Mr. Raghu Naik, (RW1) Assistant Manager, of opposite party filed affidavit evidence and answered the interrogatories served on him and produced documents got marked at Ex.R1.  Mr. Yuvaraja Jain, (RW2) Project Officer of S.K.D.R.D.P (R), of Opposite Party filed affidavit evidence and answered the interrogatories served on him.

IV.     In view of the above said facts, the points for arise for our consideration in the case are:

1. Whether the Complainant proved that the Opposite Party committed deficiency in service?
2. If so, whether the Complainant is entitled for any of the reliefs claimed?
3. What order?

  We have considered the arguments submitted by the complainant and Opposite Party and also considered the materials that, placed before the Fora and answered the points are as follows:

                              Point No. (i) : Affirmative

                              Point No. (ii) : Affirmative

                              Point No. (iii): As per the final order.

REASONS

V.   POINTS No. (i) and (ii): 

          The case of the complainant that the complainant along with 3 family members are the members of 2^nd opposite parties medical insurance scheme by paying Rs.1,520/ as per Ex.C1.  under group insurance policy which is not disputed by the Opposite Party.  At the time of accident the complainant admitted to Dhanvanthri Hospital Puttur and spent of Rs.36,160/ as per Ex.C4 and Ex.C5.  After the discharge, the complainant filed claim before the Opposite Party No.1 as per Ex.C2 the Opposite Party No.1 stated that the claim documents should be submitted before the Opposite Party no.2 as per Ex.C3, but Opposite Party no.2 stating that complainant has not complied the requirements. On the other hand Opposite Party no.1 submitted that certain requirements mentioned at the stage of processing the claim by Opposite Party No.2 was not furnished by the complainant hence it is premature and the complainant is fully aware of the scheme and as per Niyamavali Pustaka given information regarding the procedure of Sampoorna Suraksh Scheme.  The terms and conditions as explained in the detailed Niyamavali Pustaka therefore question of issuing the policy certificate does not arise.  If the complainant furnished the photo ID card then the claim can be processed with the insurance company, without which the claim can not be processed. Now points for consideration is as per Ex.C3 Opposite Party No.1 stated that  every claimant and member of sampoorna suraksha has to submits the claim papers pertaining to health claim to M/S SKDRDP Dharmastala and not to our company  and on the other hand the Opposite Party No.2 also admitted that if the complainant furnished the proper documents then the claim can be processed.  Therefore mere admission of both the parties is sufficient to prove the case, hence claim of the complainant is jenvine. After verify the documents of Ex.C1 the Opposite Party No.2 has not served the policy conditions to the complainant is amounts to be deficiency in service.  It is well settled principal that unless policy and its conditions are served on the insured, the conditions cannot be imposed on the insured As per S.8 of the IRDA Regulations The policy shall state the primary documents required for claim, and ruling reported in 2015 IV CPJ.376 N.C.

          No evidence that opposite parties ever supplied terms and conditions of group personal accident policy Unfair trade practice proved repudiation not justified

Further the ruling reported 2009 III CPJ 246 N.C.

          Unexplained/unnoticed exclusion clauses, not binding to insured Exclusion Clauses required to be ignored if mandatory requirement of explaining Exclusion clause, not adhered by insurer/ Agent, before issuance of insurance cover

          However As per Ex.C1 the document produced by complainant himself which is issued by Opposite Party and signed by chief excutive officer of medi assist TPA India Pvt mentions the limit per family of coverage at Rs.40,000/.  The claim of complainant is less than Rs.40,000/ i.e. 36,160/ which was also not paid by the Opposite Parties which amounts to deficiency in service. Therefore considering the above facts and circumstances of the case Opposite Party No.1 and 2 commits deficiency in service and also not provide the terms and conditions of the policy is unfair trade practice. Hence the Opposite Party No.1 and 2 jointly and severally shall pay Rs.36,160/ along with 9% interest from the date of discharge i.e. 11.7.2014 and to pay of Rs.10,000/ as compensation towards mental agony and Rs.5,000/ as litigation expenses is justified.  As such answer to point No.1 and 2 Affirmative.

          In the result, accordingly we pass the following Order.

ORDER

                The complaint is allowed with cost. Opposite Party No.1 and 2 jointly and severally shall pay Rs.36,160/ along with 9% interest from 11.7.2014 and to pay of Rs.10,000/ as compensation and also pay Rs.5,000/ as litigation expenses.  Payment shall be made within 30 days from the date of receipt of copy of this order.

          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 dictated by Member to the Stenographer typed by him, revised and pronounced in the open court on this the 31^st 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 Complainant:

CW1  Mr. Bhaskara

Documents marked on behalf of the Complainant:

Ex.C1: 01.04.2014: Copy of the membership receipt for the year 2014.15.

Ex.C2: 13.8.2014: Copy of the claim letter.

Ex.C3: 16.9.2014: Reply of the 1^st Opposite Party.

Ex.C4: 11.7.2014: Copy of the discharge summary.

Ex.C5: 11.7.2014: Copies of the bills (11).

Ex.C6: 17.11.2014: O/c of the regd lawyers notice.

Ex.C7: 18.11.2014: Postal acknowledge of 2^nd Opposite Party.

Witnesses examined on behalf of the Opposite Parties:

RW1: Mr. Raghu Naik,  Assistant Manager

RW2: Mr. Yuvaraja Jain, Project Officer of S.K.D.R.D.P (R)

Documents marked on behalf of the Opposite Parties:

Ex.R1: Copy of the Niyamavali Pustaka.

Dated: 31.05.2017                                    MEMBER