This Complaint coming up before us for hearing on 14-02-12 in the presence of Sri Y. Sita Ramayya, advocate for complainants,                     Sri K. Srinivasa Rao, advocate for 1^st opposite party, 2^nd opposite party remained absent and set exparte, upon perusing the material on record and having stood over till this day for consideration this Forum made the following:-

O R D E R

Per Sri A. Hazarath Rao,  President:-      The complainants filed this complaint under section 12 of the Consumer Protection Act seeking Rs.1895/- together with interest @24% p.a., from the date of submission of claim bill on 28-06-06 and Rs.1,000/- towards legal expenses.

2.   In brief the averments of the complaint are these:

        The 1^st complainant for the benefit and social safety of its milk producers including the 2^nd complainant obtained group Medi-claim (floater policy) for the years 2005-2006 and 2006-2007 covering the risk for the period from 11-08-05 to 10-08-06 and from 11-08-06 to 10-08-07.   It is the primary responsibility of the 1^st complainant to take up the cause of milk producers having obtained the said policy for medical reimbursement.   There is no conflicting interest between the complainants. The                         2^nd complainant had undergone treatment for typhoid at the hospital of Dr. Papa Rao, KNM Nursing Home, Cherukupalli, and incurred Rs.1895/-.   The 1^st complainant forwarded the claim of the 2^nd complainant who in turn sent them to the opposite parties on 28-06-06.

        The 1^st complainant got issued legal notice on 17-02-11 to the opposite parties as they failed to respond properly.   Both the opposite parties received legal notice and kept quite without settling the claim.   Non payment of claim to the complainants amounted to deficiency of service.   The claim therefore be allowed.

3.   The 2^nd opposite party remained exparte.

4.  The contention of the 1^st opposite party in brief is hereunder:

        The 1^st complainant never forwarded the claim of the complainant on 28-06-06.   The 1^st complainant did not receive notice dated 17-02-11.   After receipt of summons from the Forum the 1^st opposite party made correspondence with the 2^nd opposite party and requested to send claim dockets if any made with them.   The 1^st opposite party did not get any information from the 2^nd opposite party as there was no claim.   Domiciliary hospitalization is excluded besides pre and post hospitalization expenses.   The complainants failed to file case sheet, discharge summary and medical bills.   The liability of the 1^st opposite party is contractual but not statutory.   The complainants colluded and filed this frivolous case to have unlawful gain.   The complaint therefore be dismissed.

5.     Exs.A-1 to A-7 on behalf of complainants and Exs.B-1 and B-2 on behalf of 1^st opposite party were marked.

6.      Now the points that arose for consideration in this complaint are:      

1. Whether the opposite parties committed deficiency of service?
2. To what relief?

7.   POINT No.1:-  Ex.A-1 revealed that the 1^st complainant took Group Medi-claim (floater policy) covering 5099 families 15022 persons for the period from 11-08-05 to 10-08-06.  Ex.A-2 revealed that the 1^st complainant added 26 families (76 members) from 30-09-05 to 10-08-06.  Ex.A-3 revealed that the 1^st complainant took group Medi-claim (floater policy) for 1900 families covering 5826 persons for the period from 11-08-06 to               10-08-07.   The 1^st complainant included 2741 families 4641 members additionally from 31-08-06 to 10-08-07 as seen from Ex.A-4.   The opposite parties have not denied about Exs.A-1 to A-4.

8.     The complaint as well as affidavit of the 2^nd complainant was silent when he took treatment for typhoid at the hospital of Dr. Papa Rao, KNM Nursing Home, Cherukupalli.  It is the contention of the 2^nd complainant that he put in application with details of medical expenses to the 1^st complainant who in turn forwarded the same to the 1^st opposite party on 28-06-06.   Ex.A-6 is o/c of notice issued to the opposite parties.   The relevant portion in Ex.A-6 is extracted below:

        “My client obtained group Medi-claim policies for Sangam Milk Producers during the years of 2005-2006 & 2006-2007 from No.1 of you.  No.2 of you is settling the claims and is the third party administrator settling the Medi-claims on behalf of No.1 among you.   My client paid huge amounts towards premium for “MEDICLAIM POLICY”.   Inspite of several letters and demands both of you did not settle the Medi-claims in respect of 27 persons as per Annexure-I and 11 persons in respect of Annexure-II which are enclosed herewith”.

9.  Nowhere in Ex.A-6 it was mentioned that the 1^st complainant forwarded the claim of the 2^nd complainant with relevant documents on 28-06-06 as averred in the complaint. The burden is on the complainants to prove that they forwarded the claim papers along with relevant documents as a negative aspect cannot be proved by adducing positive evidence.

10.   Relying on the judgment of Supreme Court rendered in Kandimalla Raghavaiah and company vs. National Insurance Company Limited 2009 CTJ 950 (SC) the National Consumer Disputes Redressal Commission in Lakshmi Bhai and others vs. ICICI Lombard General Insurance Company Limited and others 2011 (4) CPR 64 (NC) held 

                        “The cases where such payment is not made,                              would fall in one of the following categories—

1).  Where no claim is made either with nodal officer or the Insurance Company, within 2 years of date of death such claims shall be barred by limitation.

2).  Cases where claim is made to nodal officer or nodal officer has forwarded the claim to Insurance Company or claim has been directly filed with Insurance Company within 2 years of the death and the claim has remained undecided. In such a case the cause of action will continue till the day the Respondent/insurance Company pays or rejects the claim.

3). In a case where the Respondent/insurance company rejects the claim, the cause of action arises again from the date of such rejection.

11.   The complainants relied on Ex.A-5 letter said to have been addressed to the 1^st opposite party which it denied.  The 1^st complainant did not file any proof to show that it forwarded the claim of the 2^nd complainant along with necessary documents for processing.   In the absence of such proof and non mentioning of Ex.A-5 in A-6 lent support to the contention of the 1^st opposite party about the falsity of claim.   No prudent person will keep quite if the claim is not settled within reasonable time.  The complainants issuing Ex.A-6 notice after a period of about five years will corroborate the falsity of the claim.

12.   As the complainants failed to prove submission of claim forms to any of the opposite parties, we opine that the opposite parties did not commit any deficiency of service and the complaint is also liable to be dismissed even on the aspect of limitation.   We therefore answer this point against the complainants.

13.   POINT No.2:-   In view of above finding, in the result the complaint is dismissed without costs. 

Typed to my dictation by Junior Stenographer, corrected by us and pronounced in the open Forum dated this the 25^th day of February, 2012.

          MEMBER                                                              PRESIDENT

APPENDIX OF EVIDENCE

DOCUMENTS MARKED

For Complainant:

For opposite party:

                                                                                                  PRESIDENT