DISTRICT CONSUMER DISPUTES REDRESSAL FORUM
SOUTH 24 – PARGANAS ,
AMANTRAN BAZAR, BARUIPUR, KOLKATA-700 0144
C.C. CASE NO. _299_ OF ___2014_
DATE OF FILING : 9.7.2014 DATE OF PASSING JUDGEMENT :29/062017
Present : President : Udayan Mukhopadhyay
Member(s) : Jhunu Prasad & Subrata Sarker
COMPLAINANT :Sri Parag Mukherjee, son of late Paritosh Mukherjee of 46/A, Middle Road, Santoshpur, P.S Survey Park, Kolkata-75.
-VERSUS -
O.P/O.Ps : 1. Steel Authority of India Limited at ISPAT BHAWAN, 40, Jawahar Lal Nehru Road, P.S Shakespeare Sarani,Kol-71.
2. E Meditek (TPA) Services Limited, Shantiniketan Building, 8th Floor, Room no.6, 8, Camac Street, Kolkata-17.
3. Bajaj Allianz General Insurance Co. Ltd. GE Plaza, Opp. Gunjan Cinema, Airport Road, Blue Hill Society, Yerawada, Pune, Maharashtra – 411 006.
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J U D G E M E N T
Jhunu Prasad, Lady Member
Interference of this Forum has been sought for by the Complainant contending gross negligence, deficiency in service and unfair trade practice in rendering necessary service towards the Complainant by the Opposite Parties.
In diminutive, the case of the complainant is that the O.P.No.1 invited premium for renewal of SAIL mediclaim scheme -2013 in respect of retired employees of SAIL and their spouse.
The complainant’s father being an employee of the O.P. No.1 entered into a service contract with the O.P.No.1 and obtained Group Insurance Scheme, which was forced and subsisted even after retirement Known as SAIL MEDICAL SCHEME and the complainant’s father became an insured being entitled to the benefits of such scheme.
Thereafter the complainant’s father paid the premium regularly for the aforesaid medical scheme.
Thereafter the father of the complainant was admitted at Cure Centre Nursing Home, Kolkata on 12.03.2013, but due to not improvement of the complainant’s father, he had been brought to Medica Superspeciality Hospital on 13.09.2013 for better treatment and the complainant approached the said hospital authority for cashless treatment facility, but the said Hospital refused to provide such cashless treatment for which the father of the complainant kept unattended for an hour.
Thereafter the complainant paid Rs.10,000/- to the aforesaid hospital authority and the said hospital started treatment after getting money of Rs.10,000/- as advance, but due to gross negligence of the Medica Super Speciality Hospital the father of the complainant had died on the same date i.e. on 13.09.2013 at 2.20 P.M.
Immediately the complainant informed the O.P.No.2 regarding the deficiency of service on the part of the O.P.No.2 as well as the said Hospital authority.
Thereafter on 15.10.2013 the complainant approached the O.P.No.2 and submitted all the relevant documents for early disbursement of the total claim amount of Rs.34,778/- against the medical expenditure, but the O.P.No.1 & 2 did not disburse the claim amount of Rs.34,778/-
The complainant several times wrote letters to the O.P.No.1 & 2, but they did pay any heed to response.
Having no other alternative the complainant filed this instant case for getting relief.
Issued notices upon the O.Ps. Accordingly the Opposite parties appeared by the Ld. Advocate.
Resisting the complaint, the Opposite Parties filed separate Written Version denying each and every allegation made by the complainant in the petition of complaint contending inter alia, that the complainant has no cause of action and the complaint is not maintainable either in fact or in law and is totally false.
In the written version the O.P. N0. 1 stated that there is no mediclaim scheme for regular of SAIL during their service period. The complainant took voluntary retirement from service in and on 01.02.1992 and took voluntary membership under SAIL Medical Scheme which is an annual scheme and optional in nature. Being a benevolent employer the O.P.No.1 bears the major portion of the premium and nominal share is being contributed by its members. The medical scheme is operated and executed by the insurance Co. through its third party administrator.
As per the terms and conditions of the SAIL medical scheme the complainant’s father is covered under the said scheme. The O.P. No. 1 merely is acting as a facilitator between the ex-employees and O.P.N0.3. O.P.No.1 has neither provided any goods nor rendered any services to the complainant so as to bring a cause of action against OP.No.1. Though the said mediclaim policy of the insurance co. O.P.N0.1 has complied with all its obligations as required under the said scheme. The complainant paid the premium for membership for the years 2013 vide SBI DD No.406135 dated 04.01.2013 which was encashed by central marketing organization, Kolkata of the O.P.No.1 and full premium was paid to M/S Bajaj alliance General Insurance Co. Ltd., being the OP.No.3.
In written version the OP. No.1 stated that in this case SAIL is no way either jointly or severally responsible for any deficiency of services rendered. On the contrary, any claim is supposed to be dealt with between the father of the complainant and OP.NO.2 & 3. The O.P. No 1 neither provided any goods nor rendering any services to the complainant. Therefore, the O.P.No.1 be expunged from the instant proceedings.
In written version filed by the O.P.No.2 stated inter alia that the case is not maintainable, barred by law of limitation.
In written version filed the O.P.No.2 stated that the complainant’s father was an ex-permanent employee under the appellant and he was covered by a “Group Insurance Scheme”, launched by the O.P.No.1 for retired employees and their spouse. There is contractual relationship between the complainant and the O.P.No.2. The O.P.No.2 is the third party administrator who is only under the obligation to assess and process the claim raised by the insured and thereby advise the principle insurer O.P.No.1 and O.P.No.3.
The O.P.No.2 neither entered into any contractual relationship with the complainant nor the complainant paid any consideration whatsoever. The O.P No.2 admitted that the O.P.No.2 is only acting as a mediator and provided services relating to processing and assessing of the claims to the O.P.No.1 and O.P. No.3. The O.P.No.2 also stated that after receiving the claim of the father of the complainant under MIN 8100540: claim No.1000101317019 on 17.10.2013 of Rs.34,778/- as reimbursement, the O.P.No.2 raised some quires regarding the said claim, which was not been complied with by the complainant, for which the O.P.No.2 was not in a position to process the claim.
In light of the above the O.P.No.2 stated that the claim was left and unfulfilled and incomplete and therefore, the complaint is liable to dismissed.
In written version filed by the O.P.No.3 also stated inter alia, that the complainant has no cause of action against the O.P, Forum has no jurisdiction to adjudicate the present dispute and the case is bad for non-joinder of necessary parties and mis-joinder of unnecessary parties.
The O.P. No.3 admits that the father of the complainant was covered by virtue of a valid Group health insurance policy issued by O.P.No.3 and such policy was issued in favour of the listed employees as well as retired employee of the O.P.No.1 who paid requisite premium for such coverage.
The O.P.No.3 is the third party administrator duly licensed by the IRDA, who were dealing with claims (if any) lodged by employees as well as retired employees of the O.P.No.1 who were covered by such medical insurance policy as stated herein above. So, the O.P. No.3 had nothing to do with the same. The normal procedure followed by the insurance companies, but they are provided with requisite amount for paying bonafide claim to the concerned insured person. Therefore O.P. No.3 has no deficiency in service at all.
The O.P.No.3 also submits that the O.P.No.2 without the knowledge and consent of O.P.No.2 denied to pay cashless claim to father of the complainant and latter on did not pay the claim lodged by the complainant, therefore this O.P.No.3 has no deficiency in service at all.
Therefore, the O.P. No. 3 prayed to dismiss the complaint .
Point For Decision:-
1.Is the complainant a consumer or not?
2.Was there any negligence or deficiency in service on the part of the OPs.?
3.Whether the complainant is entitled to get any relief as prayed for ?
Decision With Reasons:-
At the time of argument the complainant and all the O.Ps filed affidavit-in-chief, Questionnaires, BNA and some Xerox copies of documents to support of their claim.
On overall evaluation of the argument advanced by the Ld. Advocates of both the parties, and on critical appreciation of the case record it is clearly evident that admittedly the father of the complainant was the Group Mediclaim policy holder of the Insurance co. and paid premium regularly.
Facts remains that the O.P Nos.2 & 3 admitted regarding treatment of the father of the complainant at Cure Centre , Kolkata, and Medica Superspeciality Hospital Kolkata and also admitted that the claim lodged by the complainant. The O.P.No.3 shifted the liability regarding payment of claim upon the shoulder of the O.P.No.2, who acted on as per instruction of the O.P.No.3. The O.P.No.2 denied the claim on the ground of non submission of cancelled cheque by the father of the complainant for NEFT purpose at the time of renewal of the policy.
Manifestly, it is found from the photocopies of the documents filed by the complainant and the O.Ps we are of the view that ground for denial of such claim by the O.Ps is baseless. The O.P.Nos.2 & 3 ought to have asked for canceled cheque at the time of settlement of claim raised by the complainant. To support such conduct of the O.P.No.2 by the O.P.No.3 is baseless and not convinced to us and accordingly O.P No.2 & 3 committed deficiency in performance of their Acts and conducts u/s 2(i)(g) of C.P. Act 1986.
Regarding Locustandi of the complainant as consumer, We are of the view that neither of the parties raise any dispute regarding the complainant as only legal heir of late Paritosh Mukherjee. In support of such statement the O.Ps did no furnish any particulars of other legal heirs on this case.
Therefore, We have no hesitation to hold that the complainant as legal heir(son) and legal representative of Late Paritosh Mukherjee can file complaint and the complainant is a consumer u/s 2(i)(c) of C.P. Act 1986.
Accordingly the complainant gets relief as prayed for.
In the result complaint succeeds and we pass
ORDER
That the complaint be and the same is allowed on contest against the O.Ps with cost of Rs.6000/-.
That the O.P.No.2. is directed to reimbursement of Rs. 34,778/- to the complainant within one month from the date of this order.
That the O.Ps are jointly and severally directed to pay a sum of Rs.21,000/-only to the complainant, as compensation for suffering harassment and mental agony, within one month from the date of this order.
That the O.Ps are jointly and severally also directed to pay a sum of Rs.6,000/-only to the complainant as litigation cost within one month from the date of this order.
In the event of non compliance of any portion of the executable order by the Opposite parties within the above specified period, the Opposite parties shall have to pay a sum of Rs.50/-per day from the date of this order till its realization, as punitive damage, which shall be deposited by the Opposite parties in the State Consumer Welfare Fund.
Let a copy of the order be supplied to the parties free of cost when applied for.
Member Member President
Dictated and corrected by me
Member
The judgment in separate sheet is ready and is delivered in open Forum. As it is ,
ORDER
That the complaint be and the same is allowed on contest against the O.Ps with cost of Rs.6000/-.
That the O.P.No.2. is directed to reimbursement of Rs. 34,778/- to the complainant within one month from the date of this order.
That the O.Ps are jointly and severally directed to pay a sum of Rs.21,000/-only to the complainant, as compensation for suffering harassment and mental agony, within one month from the date of this order.
That the O.Ps are jointly and severally also directed to pay a sum of Rs.6,000/-only to the complainant as litigation cost within one month from the date of this order.
In the event of non compliance of any portion of the executable order by the Opposite parties within the above specified period, the Opposite parties shall have to pay a sum of Rs.50/-per day from the date of this order till its realization, as punitive damage, which shall be deposited by the Opposite parties in the State Consumer Welfare Fund.
Let a copy of the order be supplied to the parties free of cost when applied for.
Member Member President
