BEFORE THE DAKSHINA KANNADA DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, ADDITIONAL BENCH, MANGALORE
Dated this the 13th January 2017
PRESENT
SRI VISHWESHWARA BHAT D : HON’BLE PRESIDENT
SRI T.C. RAJASHEKAR : HON’BLE MEMBER
SMT. SHARADAMMA H.G : HON’BLE MEMBER
ORDERS IN
C.C.No.252/2014
(Admitted on 8.07.2014)
Smt. Khathija,
W/o Mahammad,
Aged about 43 years,
R/at Mudala House,
Volamogru Village,
Kumbra Post, Puttur Tq.
….. COMPLAINANT
(Advocate for the Complainant: Sri SD)
VERSUS
1. The Manager,
United India Insurance Company Ltd,
Ram Bhavana Complex,
Kodialbail,
Mangalore, D.K 01.
2. Director,
Shree Kshethra Dharmasthala
Gramabivriddi Yojane,
Sampoorna Suraksha Programme,
Dharmasthala,
Belthangady Taluk, D.K.
….......OPPOSITE PARTIES
(Advocate for the Opposite Party No.1: Sri MVSB)
(Advocate for the Opposite Party No.2: Sri UKS)
ORDER DELIVERED BY HON’BLE PRESIDENT
SRI. VISHWESHWARA BHAT D:
I. 1. The above complaint filed under Section 12 of the Consumer Protection Act by the complainant against opposite parties alleging deficiency in service claiming certain reliefs.
The brief facts of the case are as under:
The complainant contends for 2013.14 she and her husband and members of the medical insurance scheme Sampoorna Suraksha Yojane (for short SSY) and paid Rs.760/ as fee under the scheme she is entitled for reimbursement of medical expences of Rs. 20,000/ and it was opposite party No.2 insured complainant with opposite party No.1 by letter dated 25.9.2013. The complainant was treated at Dhanvanthary Hospital Puttur on 19.7.2013 for injury to right anterior axillary and discharged on 23.7.2013 and spent Rs.4,095/ for treatment. When bills discharge summary were submitted 2nd opposite party replied returning the claim documents with the advice to submit form no.2 to the regd. notice issued on 21.9.2013 opposite party No.2 furnished insurance details and the claim laid with opposite party No.1 to the claim laid under regd. notice false reply was sent. Opposite party No.1 claimed if opposite party No.2 authorises and processes the claim and approve it will be honoured by opposite party No.1. The membership issued by opposite party No.2 is against law and opposite party No.2 is duty bound to issue the Insurance Certificate with full details. Members of Shree Kshethra Dharmasthala Gramabivriddi Yojane has to be a member of SSY. Opposite party No.2 cannot instruct the member to go to a particular Hospital it is the choice and confidence to the member to go the particular hospital. Hence seeks direction to opposite parties to order payment of the Medical expenditure, compensation and litigation expences.
II. Opposite party No.1 filed written version the ground urged is in the fact complainant has voluntarily joined through opposite party No.2 and there is no deficiency at service because the relationship did not come into existence in view of the voidness of the transaction. The complainant has mentioned in the laid member with opposite party No.2 and then turning around these such issues cannot be issued under went with SKDRDP for single person premium for Rs.10,000/ at Rs.325 plus service tax and the complainant paid Rs.760/ inclusive of service tax to cover the risk of Rs 20,000/. The requirement of opposite party No.2 to the claim is complied as there was no processing with opposite party No.2 the claim made with opposite party No.1 is not maintainable.
2. Opposite party No.2 in the written version mentions the members and the SKDRD Self Help Group can participate in this program of SKDRD and can take treatment in the network hospitals only. In spite of several request the complainant had not submitted the duly filled and signed application Form B and bills and relevant medical records, copy of the ID Proof to opposite party’s branch at Puttur is not possible to opposite party No.2 and register the claim and get it sanctioned from the insurer. The head office on receipt of the original bills have returned to the complainant along with the letter stating she has to duly fill and signed application Form B and the Photo Identity Card along with original bills to the Puttur Project Office, Suraksha Desk with the member of the scheme than they should abide by the terms and conditions of the scheme. The aim of the scheme is to reimburse the medical expenses and are covered and not for all sundry diseases subject to their eligibility. It is also asserted in case complainant duly filled applications and furnishes the Photo ID Card the claim can be preceded with the insurance company without the claim cannot be processed. Hence seeks dismissal.
3. In support of the above complainants Smt. Khathija filed affidavit evidence as CW1 and answered the interrogatories served on her and produced documents got marked Ex.C1 to C11 as detailed in the annexure here below. On behalf of the opposite parties Mr. Amar Kumar Sinha (RW1) Senior Divisional Manager, and Mr. Abraham M.K (RW2) Director, Sampoorna Suraksha, SKDRDP (R) also filed affidavit evidence and answered the interrogatories served on them got marked Ex.R1 to R3 as detailed in the annexure here below.
In view of the above said facts, the points for consideration in the case are:
- Whether the Complainant is a consumer and the dispute between the parties?
- If so, whether the Complainant is entitled for any of the reliefs claimed?
- What order?
We have considered the notes of arguments submitted by the learned counsel and also considered the material that was placed before this Forum and answer the points are as follows:
Point No. (i): Affirmative
Point No. (ii): Negative
Point No. (iii): As per the final order.
REASONS
IV. POINTS No. (i): In this case the complainant a member of the project SSY of opposite party No.2 and has paid the amount to cover the medical risk is not disputed. However the claim made by complainant for reimbursement of the expenses towards the treatment to complainant towards hospitalization when laid with opposite party No.1 the insure company was rejected by opposite party No.1 and when again it was laid with opposite party No.2 it was rejected on the ground the required documents is not furnished. Hence there is dispute between the complainant the consumer and the opposite parties the service providers. Hence answer point No.1 in the affirmative.
POINTS No.(ii): It is not in dispute that the complainant sent the medical bills directly to opposite party No.1 after getting particular of the insurance policy number and that was rejected by opposite party No.1 on the ground that as it was a group insurance done through opposite party No.2 of its members opposite party No.2 has to process the claims. When that was not done by complainant by submitting the required document to opposite party No.2 the rejection of the claim by opposite party No.1 in our view is justified.
2. That apart the complainant again submitted medical bill to opposite party No.2 but without the required documentations namely the ID card, of complainant when the claim is nor made reimbursement of medical expence before the concerned authority of opposite party No.2 by fulfilling all the requirements in our view the rejection of such claim for including particulars as rightly done by on behalf of opposite party No.2 in our is fully justified.
3. In fact opposite party No.2 had no opportunity to approve as required of complainant as to the particulars are not furnished. But the complainant in fact as rightly pointed out by learned counsel for opposite party No.2 in our opinion it is open to complainant to file fresh claim with the required documentation including ID Card before opposite party No.2 and if opposite party No.2 is satisfied as to the genuineness of the claim and admissibly under the rules of the scheme before opposite party No.2 as pointed out it would be sent to opposite party No.1 for making payment. Hence when required documentations were not furnish by complainant before opposite party No.2 the complainant cannot make an issue of the same when he himself is at fault. Before we close in case complainant furnishes the full particulars before opposite party No.2 as required under rules of opposite party No.2 opposite party as mentioned in the written version could process the claim and forwarding to opposite party No.1 the insurance company for making payment if admissible under rules. Hence we answer point No.2 in the negative.
POINTS No. (iii): Wherefore the following order
ORDER
The complaint is dismissed.
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 dictated by President to computer system to the Stenographer typed by her, revised and pronounced in the open court on this the 13th January 2017)
MEMBER PRESIDENT
( SRI T.C. RAJASHEKAR) (SRI VISHWESHWARA BHAT D)
D.K. District Consumer Forum D.K. District Consumer Forum
Additional Bench, Mangalore Additional Bench, Mangalore
MEMBER
( SMT. SHARADAMMA H.G)
D.K. District Consumer Forum
Additional Bench, Mangalore
ANNEXURE
Witnesses examined on behalf of the Complainant:
CW1 Smt. Khathija
Documents marked on behalf of the Complainant:
Ex.C1: 01.04.2013: Copy of the membership receipt for the Year 2013.14
Ex.C2: 25.07.2013: Copy of the claim letter
Ex.C3: 02.08.2013: Reply of the Opposite party
Ex.C4: 23.07.2013: Copy of the discharge summary
Ex.C5: 23.07.2013: Copies of the bills (6)
Ex.C6: 21.09.2013: O/c of the regd lawyer’s notice
Ex.C7: 25.09.2013: Reply of the 2nd opposite party
Ex.C8: 21.11.2013: O/c of the regd lawyer’s notice
Ex.C9: 02.12.2013: Reply of the 1st opposite party
Ex.C10:22.11.2013: Postal Acknowledgement of 2nd Opposite party
Ex.C11: : Postal Acknowledgement of 2nd Opposite party
Witnesses examined on behalf of the Opposite Parties:
RW1 Mr. Amar Kumar Sinha, Senior Divisional Manager,
RW2 Mr. Abraham M.K, Director, Sampoorna Suraksha, SKDRDP (R)
Documents marked on behalf of the Opposite Parties:
Ex.R1: Copy of the Mahithi Patra
Ex.R2: Office copy of the letter dated 02.08.2013 along with Acknowledgement
Ex.R3: Office copy of the Reminder dated 20.8.2013 along with Postal receipt
Dated: 13.01.2017 PRESIDENT
