BEFORE THE DAKSHINA KANNADA DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, ADDITIONAL BENCH, MANGALORE
Dated this the 7th April 2017
PRESENT
SRI VISHWESHWARA BHAT D : HON’BLE PRESIDENT
SRI T.C. RAJASHEKAR : HON’BLE MEMBER
ORDERS IN
C.C.No.105/2014
(Admitted on 27.03.2014)
SMt. Veena,
W/o Lolaksha,
Aged about 36 years,
R/at. Karinja House,
Kanakamajalu Village and P.O.
Sullia Taluk, D.K.
….. COMPLAINANT
(Advocate for the Complainant: Sri SD)
VERSUS
- Project Officer,
Shri kshethra Dharmasthala,
Gramabivriddi Yojane,
Chennakeshava Temple Road,
Sullia, D.K.
- The Divisional Manager,
The Oriental Insurance Co.Ltd,
Beauty Plaza, II Floor,
Balmata Road, Mangalore 01.
….......OPPOSITE PARTIES
(Advocate for the Opposite Party No.1 : Sri UKS)
(Advocate for the Opposite Party No.1 : Sri AKK)
ORDER DELIVERED BY HON’BLE MEMBER
SRI T.C. RAJASHEKAR:
I. 1. The above complaint filed under Section 12 of the Consumer Protection Act 1986 alleging deficiency in service against the Opposite Party claiming, to pay Rs.6,970/ to complainant with 12% interest from 6.4.2013 till payment, to pay Rs.20,000/ as compensation, to pay Rs.10,000/ as expenses and such other reliefs.
2. In support of the above complainant Smt. Veena, filed affidavit evidence as CW1 and answered the interrogatories served on him and produced documents got marked at Ex.C1 to C7 as detailed in the annexure here below. On behalf of the opposite parties Mr. Yuvaraja Jain (RW1) Project officer of S.K.D.R.D.P.(R), also filed affidavit evidence and answered the interrogatories served on him and produced documents got marked at Ex.R1 to R2 as detailed in the annexure here below. Raghu Naik, (RW2) also filed affidavit evidence and answered the interrogatories served on him.
The brief facts of the case are as under:
We have perused the complaint and the version averments. This dispute is with regard to repudiation of medical insurance claim. The complainant states that he is the member of SAMPOORNA SURAKSHA YOJANE sponsored by the opposite party No 1. Under the scheme the complainant and his family are entitled for the medical expenses reimbursement under group insurance scheme and she had paid the premium also. She was admitted to DHANVANTHARY HOSPITAL Puttur and delivered a baby. On submission of the hospital expenses bill the opposite parties not settled the claim. The opposite party contesting the case stated that the complainant had not followed the procedure of claim settlement. As per procedure the insured has to submit claim in a prescribed form with identification proof to the opposite party no 1 branch at Puttur. Instead the complaint had sent the bills to the opposite party No 1 H.O. directly without submitting prescribed form and the ID proof. Even after receiving the bill at H.O. the opposite party had written a letter requesting to send the required form signed and with ID proof to the Puttur branch office, the complaint never complied the request. Still the opposite party No 1 is ready to consider the claim if prescribed form with identification proof submitted at its Puttur branch. These are being the facts of dispute we considered the following
POINTS FOR ADJUDICATION
We have considered the evidence lead by the parties and laid our hand on the documents produced. The admitted facts are, the issue of membership to the complaint under the SAMPOORNA SURAKSHA YOJANE and coverage under the group insurance medical policy, the complainant admission to hospital and delivery expenses spent by the complainant. It is also admitted fact that, the complainant had sent the medical expenses bill to the opposite party No 1 head office. It is denied that the complainant had sent all prescribed documents for applying for the claim, and the deficiency in service on the part of them. The opposite party No 2 is the insurance company which has insured the group policy and its roll only to reimburse to the opposite party No 1 if any claim made on behalf of member and
supported opposite party No 1s contentions. Admissions and the denials reconciled and in resolving this dispute we considered the following points.
- Whether the complainant is the consumer under the consumer protection Act 1986?
- Whether there is deficiency in service on the part of the opposite party?
- Whether complainant entitled for the relief prayed for?
- What order?
We have examined the evidence produced and the documents produced. The party notes of arguments taken note off and heard the counsels of the parties and answered the above points as under:
- In the affirmative.
- In the negative.
- In the negative.
- As per delivered order.
REASON
POINT NO 1: The complainant had produced the EX C1is the membership detail in which it is shown as the complainant is the member with membership card no 3472562, and the insurance is covered by the oriental insurance company, Mangalore. This is sufficient to hold the complainant is the beneficiary of the group insurance scheme taken under SAMPOORNA SURAKSHA YOJANE. Hence we answered the point no 1 in the affirmative.
POINT NO 2: The dispute before us is the opposite party not honored the claim of medical expenses made by the complainant. The opposite party says they have not repudiated the claim till. The complaint had not followed prescribed procedure for claim settlement, the complainant not signed the prescribed Form B application and the identity proof not given for identifying the claimant who has taken treatment.
2. We have referred the member ship card no 3472562 issued to the complainant. It contains some information to the member and instruction to the insurer. The dotted instruction second one is for the insurer which states that the insurance company the second opposite party herein has to confirm the persons/patients identification as per SOP after obtaining suitable identification card. From this it is clear that the complainant knows that the identification is required for taking treatment and claim settlement.
EX C2 is the document the complainant had written to the opposite party No 1 H.O. stating that he has spent Rs 6970/ for medical expenses and his card no is SUL 3472562, he is sending the bills for delivery expensed, and he is sending all related documents.
EX C 3 is the letter written by the opposite party No 1 informing the complainant that he had not filed the Form no 2 and enclosed the identity card copy for claim settlement, and requesting the complainant to get required Form from the Sulya branch and submit the same with ID proof. The letter referred to MAHITI PATRA which is claimed to have been given with the membership card. As per MAHITI PATRA under clause 3.1 to 3.18 the claim has to be applied.
3. As per opposite party contention is the complainant not complied with the claim formality and they are ready to consider if the claim is lodged as per procedure. It is not the contention of the complainant that he had claimed the amount as per procedure with From B and attached the photo ID proof and in spite the opposite party not settled his claim. Neither the complainant complied with the request letter dated 10.07.2013 written by the opposite party No 1 nor stated that he had already complied with the request.
4. The other point is the complainant stated that he has not provided with the MAHITI PATRA. The opposite party stated that they have provided with the MAHITI PATRA to the complainant while giving membership card. We have gone through the interrogatories served by the opposite party No 1. To a suggestion In question no 18: even in spite of the several requests by this opposite party you have not complied by giving duly filled and signed application and identity proof to the to the Suraksha Desk Sulya the complainant replies as I say it does not arise. From this it is established that the complainant not provided documents and information as required for lodging the claim. The complainant not stated anywhere throughout that he has submitted the Form no B/2 and submitted his ID proof. It is not the submission of the complainant that he do not have ID card or any difficulty in producing it. We do not understand why the complainant is hesitant to submit required claim Form and valid ID proof for claiming the expenses. With this our observation is the complainant while submitting the claim not adopted the procedure agreed upon and the opposite parties are still ready to consider if claimed as per procedure. We to admit that there must be a procedure and identification of the person taken treatment to avoid the misuse of the facility and also to make the benefit to reach the right person. We have not come across any deficiency in service on the part of the opposite parties and held the point no 2 in the negative.
POINT NO 3: As per our above discussion the conclusion is the complainant not approached the opposite parties in a established way and there is no repudiation of claim till date hence we do not find any dispute and the complaint is premature deserve to be dismissed with a liberty to the complainant to approach the opposite party with required documents and in prescribed Form supported by proper ID proof.
POINT NO 4: In the result of above discussion and the adjudication of the points we deliver the following
ORDER
The complaint is dismissed. The complainant is at liberty to approach opposite parties as aforesaid.
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 typed by Member, revised and pronounced in the open court on this the 7th April 2017)
MEMBER PRESIDENT
(T.C. RAJASHEKAR) (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. Veena
Documents marked on behalf of the Complainant:
Ex.C1: Copy of the membership receipt for the year 2013-14
Ex.C2: 15.4.2013: Copy of the claim letter.
Ex.C3: 10.7.2013: Reply of the Opposite Party.
Ex.C4: 6.4.2013: Copy of the discharge summary.
Ex.C5: 6.4.2013: Copies of the bills (5).
Ex.C6: 4.7.2013: O/c of the regd lawyer’s notice.
Ex.C7: 10.7.2013: Reply of the Opposite Party.
Witnesses examined on behalf of the Opposite Parties:
RW1 Mr. Yuvaraja Jain, Project officer of S.K.D.R.D.P.(R).
RW2 Raghu Naik,
Documents marked on behalf of the Opposite Parties:
Ex.R1: copy of the Mahithi patra.
Ex.R2: Office copy of the letter dated 10.7.2013 along with acknowledgement.
Dated: 7.4.2017 MEMBER
