BEFORE THE DAKSHINA KANNADA DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, MANGALORE
Dated this the 31st MARCH 2016
PRESENT
SMT. ASHA SHETTY : HON’BLE PRESIDENT
SMT.LAVANYA M. RAI : HON’BLE MEMBER
COMPLAINT NO.257/2013
(Admitted on 21.09.2013)
Sadananda S.
S/o Muthappa Poojary,
Aged about 36 years,
R/at. Sowthemaru House,
Kudmaru Village & P.O.
Puttur Tq, D.K …….. COMPLAINANT
(Advocate for Complainant: Sri. Sanjay D)
VERSUS
1. Project Officer,
Shree Kshethra Dharmasthala,
Gramabivriddi Yojane,
Dharmasthala Building,
Puttur Branch,
Puttur.D.K.
2. Senior Divisional Manager,
The Oriental Insurance Co. Ltd.,
Divisional Office,
Beauty Plaza, Balmatta Road,
Mangalore-01. ……OPPOSITE PARTIES
(Advocate for Opposite Party No 1 & 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 stated that, the complainant along with his two family members are the members of the 1st opposite party Yojane as per receipt No. 438741 for the period 2011-12. The complainant has paid Rs. 700/- to the 1st opposite party as membership fee and the complainant’s family is entitled for an insured amount of Rs. 15,000/- under the Yojane and the 1st opposite party is liable to reimburse the medical expenses.
When the matter stood thus, the complainant’s wife admitted to Adarsha Hospital Puttur for delivery on 13.08.2011 and discharged on 16.08.2011 and spent Rs. 3,939/- for medical expenses. The complainant has sent the claim to 1st Opposite Party with original documents but the Opposite Party failed to reimburse the claim. It is stated that no information or booklet were given to complainant regarding any claim procedures. It is stated that the member of the 1st opposite party is compalcerly made as member of Samporna Surkasha scheme. The opposite parties are bound to reimburse the claim amount but they have not paid till this date, hence 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.3,939/- including 12% interest from 16.08.2011 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. The Opposite Party No. 1 stated that Samporna Surkasha scheme is unique program wherein interested participant join together to bring scrutiny to their insurance /life during ailment/accidents hospitalization. SKDRDP self-help group the total subscription amount is paid as premium by the SKDRDP to the insurance to look after eligible member’s up to the prefixed amount and to meet the medical treatment expenses during hospitalization. The complainant is insured with 1st Opposite Party. 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 medclaim 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, according to the agreed terms of the scheme, member has to submit application form and bills with relevant medical records to the 1st Opposite Party. On verification of documents of the complainant 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 and sought for dismissal of the complaint. Opposite party No. 2 stated that the complainant was the member of the SKDRDP and has opted for SSS. On processing and scrutiny of the claim of the complainant found that the claim for reimbursement of delivery charges is sought for comes within the waiting period of 12 months from the issuance of the policy. The said claim is not entitled /eligible for re-imbursement, there is no deficiency in service and sought for the dismissal of the complaint. .
III. 1. In support of the complaint, Sri Sadananda S. (CW1) – Complainant filed affidavit reiterating what has been stated in the complaint and answered the interrogatories served on his and produced Ex. C1 to C7. One Mr. Vasantha B (RW-1) of Opposite Party No. 1 and one Mr. Raghu Naik (RW-2) of opposite party No. 2 filed counter affidavit and answered the interrogatories served on them. EX-R-1 to R3 were marked for the Opposite Parties.
In view of the above said facts, the points now that arise for our consideration in this case are as under:
(i) Whether the Complainant proves that the Opposite Parties have committed deficiency in service?
(ii) If so, whether the Complainant is entitled for the reliefs claimed?
(iii) 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 1st 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. 1st 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 2nd 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 1st opposite party. Just because the complainant not sent the documents to the 2nd opposite party, the insurance company cannot treat the claim arbitrarily on the other hand the 1st opposite party should have forwarded the documents to the 2nd opposite party instead of repudiating the claim randomly. Further the 1st 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 direct the Opposite Party No. 2 shall pay Rs. 3,939/- 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.
In the result, we pass the following:
ORDER
The complaint is allowed, opposite Party No. 2 shall pay Rs. 3,939/- (Rupees three thousand nine hundred and thirty nine only) along with interest @ 12% p.a. from the date of complaint till the date of payment and also pay Rs. 3,000/-(Rupees three thousand only) as cost of litigation expenses. Payment shall be made within 30 days from the date of receipt of this order.
Complaint against opposite party No. 1 is hereby dismissed.
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 31st day of MARCH- 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 Sadananda S Complainant.
Documents produced on behalf of the Complainant:
Ex C1: : Copy of the membership receipt
for the year 2011-12.
Ex C2: 18.11.2011: Copy of the claim letter.
Ex C3: 22.11.2011: Reply of the 1st Opposite Party.
Ex C4: 16.08.2011: Copy of the discharge summary.
Ex C5: 16.08.2011: Copies of the bills (4).
Ex C6: 13.01.2012: O/C of the regd lawyer’s notice.
Ex C7: 30.01.2012: Reply of the 1st opposite Party with
repudiation.
Witnesses examined on behalf of the Opposite Parties:
RW-1: Mr. Vasantha B Opposite Party No.1 and
RW-2: Mr. Raghu Naik Assistant Manager, Oriental Insurance Co., Balmatta Road, Mangalore opposite Party No. 2.
Documents produced on behalf of the Opposite Parties:
Ex-R-1: Original Mahithi Patra.
Ex-R-2: Xerox copy of the Membership form.
Ex-R-3: Copy of the policy along with prospectus.
Dated:31-03-2016 PRESIDENT
31.03.2016.
ORDER
The complaint is allowed, opposite Party No. 2 shall pay Rs. 3,939/- (Rupees three thousand nine hundred and thirty nine only) 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.
Complaint against opposite party No. 1 is hereby dismissed.
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 31st day of MARCH- 2016).
PRESIDENT MEMBER
(SMT. ASHA SHETTY) (SMT. LAVANYA M.RAI)
D.K. District Consumer Forum D.K. District Consumer Forum
Mangalore. Mangalore.
