Branch Manager V/S K.R.N. Kurup - Consumer Court Case

Kerala

Pathanamthitta

120/06

K.R.N. Kurup - Complainant(s)

Versus

Branch Manager - Opp.Party(s)

15 Oct 2008

ORDER

Pathanamthitta
Consumer Disputes Redressal Forum ,Doctor's Lane Near General Hospital,Pathanamthitta,Kerala,Phone:04682223699
consumer case(CC) No. 120/06

K.R.N. Kurup						...........Appellant(s)
Vs.
Branch Manager						...........Respondent(s)

BEFORE:

Complainant(s)/Appellant(s):

OppositeParty/Respondent(s):

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ORDER

Smt. C. Lathika Bhai (Member): The complainant K.R.N. Kurup, Mavilathekkethil, Kurampala, Pandalam has filed this complaint against the opposite parties for getting a relief from the Forum. The complainants case is as follows: The complainant is a retired employee of Steel Authority of India. The complainant and his wife are covered under the Group Medi-Claim Insurance Policy introduced by the Steel Authority of India Ltd. in favour of their retired employees. This insurance scheme is operating through the United India Insurance Co.Ltd. Claim index No. of the complainant is MIN 04200578 and spouse is 04200579. On 12.01.2006, the complainant had sent two medical bills to the 1st opposite party, one amounting to Rs.229-93 for the treatment of the complainant and the other amounting to Rs.1,375-86 of his spouse. Again on 11.05.2006, the complainant had sent two medical bills to the 1st opposite party for Rs. 304-48 and Rs.1,858-68 of him and his spouse respectively re-imbursement. There is no reply from the opposite parties irrespective of his sent reminders. The non-payment of the medical re-imbursement of medical bills by the opposite parties is a deficiency of service and the complainant is entitled to get the amount. The complainant filed this complaint for getting the medical expenses of Rs.3,768-98 together with interest along with compensation and cost from the opposite parties. The first opposite party has filed a common version for himself and for and on behalf of the second opposite party also. The opposite parties admitted that the complainant and his spouse are covered under the group insurance medi-claim policy issued by the Steel Authority of India Ltd. in favour of their retired employees and also admitted that the complainant had lodged a claim for Rs.3,768-95 as re-imbursement of medical expenses of him and his spouse. Out of the above said claim, the claim sent on 12.01.2006 for Rs.229-93 as the medical expenses of the complainant and Rs.1,369/- as the medical expenses of the spouse were already settled by them. The claim sent on 11.05.2006 was not settled because the treatment was done at NSS Medical Mission Hospital, which is not an approved hospital, by Steel Authority of India Ltd. for getting the benefits under this insurance scheme. The SAIL had prepared a list of hospitals only from where their employees can take treatment for the purpose of this insurance claim. NSS Medical Mission Hospital, Pandalam where the complainant and his spouse had availed treatment is not recognised by SAIL and hence they did not settled the claim. The complainant is not entitled to claim the reimbursement of medical bills issued from a hospital, which is not, recognised by SAIL and hence repudiated the claim. The opposite parties canvassed for dismissal of the complaint. The following points are raised for consideration: (1) Whether the complaint is maintainable before this Forum? (2) Whether the complainant is entitled to get a relief as prayed for in the complaint? (3) Reliefs and Costs? The evidence in this case consists of the oral evidence of the complainant who has been examined as PW1 and Exts.A1 to A15 which are marked on the basis of the proof affidavit filed by him. For the opposite parties, no oral evidence. Exts.B1 and B1(b) were marked through PW1. After closure of the evidence, both sides heard. Point No.1: The complainant availed service from the opposite parties and the complainant is a consumer of the opposite parties and the dispute is regarding the deficiency of service. Hence the complaint is maintainable before the Forum. Points 2 and 3: In order to prove the complainants case, the complainant adduced oral evidence as PW1. PW1 stated that his claim for reimbursement of medical expenses was repudiated by the opposite parties due to the reason that treatment was taken from NSS Medical Mission Hospital which is not an approved hospital of SAIL. The documents produced by PW1 are marked as Exts.A1 to A15. PW1 prays for allowing the complaint. The learned counsel for the opposite parties cross-examined PW1. At the time of cross examination, the book-let relating to the group medi-claim scheme for the year 2005 produced by the opposite parties is marked through PW1as Ext.B1. 4th page in Ext.B1 is marked as Ext.B1(a) and 15th page of Ext.B1, the list of approved hospitals by SAIL, the 32nd column stating the name of Christian Mission Hospital, Pandalam is marked as Ext.B1(c). The documents marked from the side of the complainant, Ext.A1 is the copy of covering letter sent along with the claim formto the opposite parties. Ext.A2 is the policy renewal certificate dated 27.01.2005. Ext.A3 is the recognition letter from Govt. of India, Ministry of Health stating the recognition of NSS Medical Hospital, Pandalam as per C.S. rules. Ext.A4 is the copy of letter sent to the opposite parties on 14.04.2006. Ext.A5 is the certificate of posting of Ext.A4. Ext.A6 is the copy of claim form sent on 9.01.2006. Ext.A7 is the medical bill for the treatment of complainant dated 26.12.2005. Ext.A8 is the copy of claim form of complainants wife dated 9.01.2006 sent to the opposite parties. Ext.A9 is the medical bills for the treatment of complainants wife. Ext.A10 is the copy of letter-dated 10.05.2006 sent to the opposite parties by the complainant. Ext.A11 is the Policy Renewal Certificate dated 13.02.2006. Ext.A12 is the copy of claim form dated 10.05.2006. Ext.A13 is the copy of medical bills for the treatment of the complainant. Ext.A14 is the copy of complainants wifes OPD claim form dated 10.05.2006. The relevant medical bill for Ext.A14 claim for is Ext.A15. The documents marked from the side of opposite parties, Ext.B1 is the booklet relating to the conditions of medi-claim policy agreement. Ext.B1(a) is the 4th page of Ext.B1 details regarding the OPD treatment and Ext.B1(b) is the 32nd coloumn, 15th page of Ext.B1 stating the name of Christian Mission Hospital approved by SAIL for the purpose of mediclaim insurance. On perusal of the evidence in this case, the complainant had lodged two claims for getting the medical expenses incurred for the treatment of him and his wife at NSS Medical Mission Hospital, Pandalam during the coverage of medi-claim insurance scheme. The contention of the opposite parties is that the medical bills for the treatment availed from NSS Medical Mission Hospital is not allowable that hospital is not approved by SAIL. The SAIL had prepared a list of hospitals from where the employees avail treatment for the purpose of medical reimbursement under this scheme. NSS Medical Mission Hospital is not a recognised hospital as per list by SAIL and the medical expenses for the treatment done in that hospital cannot be allowable. Ext.B1 the booklet containing the conditions and details of the medi-claim policy for the year 2005 had listed the approved hospitals for OPD treatment under SAIL medi=claim scheme. Ext.B1(b) stating the name of Christian Mission Hospital, Pandalam is an approved hospital by SAIL. It is pertinent to note that the opposite parties allowed the complainants claim of medical expenses for the treatment done at NSS Medical Mission Hospital upto 2005 even through it is not an approved hospital of SAIL. Medical expenses for the treatment done at NSS Medical Mission Hospital from 12.02.2005 to 26.12.2005 were allowed by the opposite parties. The repudiated claim is in respect of the medical bills from 2006. But as per Ext.B1(b), Christian Mission Hospital, Pandalam was approved by SAIL in the year 2005. The Christian Mission Hospital, Pandalam is very nearer to the NSS Medical Mission Hospital and from the residence of the complainant. The complainant can avail treatment from there as it is an approved hospital for this purpose. But the complainant failed to avoid treatment from an approved hospital Pandalam even after approving an hospital at Pandalam. Ext.A3, the letter from Govt. of India, Ministry of Health stating the recognition of NSS Medical Mission Hospital under CS (MA) Rules. The date of issuance of Ext.A3 is March 1987. Ext.B1 was published in the year 2005 and in Ext.B1, it is specifically stated the name of approved hospital by SAIL at Pandalam for the purpose of group medi-claim scheme. In this circumstance, we find no deficiency of service from the part of opposite parties and hence the complainants prayer is not allowable. In the result, this C.C. is dismissed. No costs. Declared in the Open Forum on this the 15th day of October, 2008. C. Lathika Bhai, (Member) Sri. Jacob Stephen (President) : Sri. N. Premkumar (Member) : Appendix: Witness examined on the side of the complainant: PW1 : K.R. Narayana Kurup. Exhibits marked on the side of the complainant: A1 : Photocopy of the letter dated 9.1.2006 along with two bills sent by the complainant to the additional second opposite party. A2 : Photocopy of the insurance renewal Certificate dated 27.1.2005. A3 : Photocopy of the letter issued by Ministry of Health & Family Welfare, Govt. of India to the Superintendent, NSS Medical Mission Hospital, Pandalam. A4 : Photocopy of the letter dated 12.4.2006 sent by the complainant to the additional second opposite party. A5 : Certificate of posting of Ext.A4 letter. A6 : Photocopy of OPD treatment claim form 9.1.2006. A7 : Photocopy of the cash bill dated 26.12.2005 for Rs.229-93 issued by NSS Medical Mission Hospital, Pandalam to the complainant. A8 : Photocopy of the OPD treatment claim form dated 9.1.2006. A9 : Photocopy of the cash bill dated 26.12.2005 for Rs.540-49 issued by NSS Medical Mission Hospital, Pandalam to the complainant. A10 : Photocopy of the letter dated 10.5.2006 along with two bills sent by the complainant to the additional second opposite party. A11 : Copy of the Insurance Renewal Certificate dated 13.2.2006. A12 : Photocopy of the OPD treatment claim form dated 10.5.2006. A13 : Photocopy of the cash bill dated 2.5.2006 for Rs.304-48 issued by NSS Medical Mission Hospital, Pandalam to the complainant. A14 : Photocopy of the OPD treatment claim form dated 10.5.2006. A15 : Photocopy of the cash bill dated 2.5.2006 for Rs.1858-68 issued by NSS Medical Mission Hospital, Pandalam to the complainant. Witness examined on the side of the opposite parties : Nil. Exhibits marked on the side of the opposite parties: B1 : Booklet containing the conditions of Group Mediclaim Scheme for the year 2005 for retired employees and their spouses. B1(a) : The relevant portion of Ext.B1 (page No.4). B1(b) : The relevant portion of Ext.B1 (page No. 15).

Smt. C. Lathika Bhai (Member): The complainant K.R.N. Kurup, Mavilathekkethil, Kurampala, Pandalam has filed this complaint against the opposite parties for getting a relief from the Forum. The complainants case is as follows: The complainant is a retired employee of Steel Authority of India. The complainant and his wife are covered under the Group Medi-Claim Insurance Policy introduced by the Steel Authority of India Ltd. in favour of their retired employees. This insurance scheme is operating through the United India Insurance Co.Ltd. Claim index No. of the complainant is MIN 04200578 and spouse is 04200579. On 12.01.2006, the complainant had sent two medical bills to the 1st opposite party, one amounting to Rs.229-93 for the treatment of the complainant and the other amounting to Rs.1,375-86 of his spouse. Again on 11.05.2006, the complainant had sent two medical bills to the 1st opposite party for Rs. 304-48 and Rs.1,858-68 of him and his spouse respectively re-imbursement. There is no reply from the opposite parties irrespective of his sent reminders. The non-payment of the medical re-imbursement of medical bills by the opposite parties is a deficiency of service and the complainant is entitled to get the amount. The complainant filed this complaint for getting the medical expenses of Rs.3,768-98 together with interest along with compensation and cost from the opposite parties. The first opposite party has filed a common version for himself and for and on behalf of the second opposite party also. The opposite parties admitted that the complainant and his spouse are covered under the group insurance medi-claim policy issued by the Steel Authority of India Ltd. in favour of their retired employees and also admitted that the complainant had lodged a claim for Rs.3,768-95 as re-imbursement of medical expenses of him and his spouse. Out of the above said claim, the claim sent on 12.01.2006 for Rs.229-93 as the medical expenses of the complainant and Rs.1,369/- as the medical expenses of the spouse were already settled by them. The claim sent on 11.05.2006 was not settled because the treatment was done at NSS Medical Mission Hospital, which is not an approved hospital, by Steel Authority of India Ltd. for getting the benefits under this insurance scheme. The SAIL had prepared a list of hospitals only from where their employees can take treatment for the purpose of this insurance claim. NSS Medical Mission Hospital, Pandalam where the complainant and his spouse had availed treatment is not recognised by SAIL and hence they did not settled the claim. The complainant is not entitled to claim the reimbursement of medical bills issued from a hospital, which is not, recognised by SAIL and hence repudiated the claim. The opposite parties canvassed for dismissal of the complaint. The following points are raised for consideration: (1) Whether the complaint is maintainable before this Forum? (2) Whether the complainant is entitled to get a relief as prayed for in the complaint? (3) Reliefs and Costs? The evidence in this case consists of the oral evidence of the complainant who has been examined as PW1 and Exts.A1 to A15 which are marked on the basis of the proof affidavit filed by him. For the opposite parties, no oral evidence. Exts.B1 and B1(b) were marked through PW1. After closure of the evidence, both sides heard. Point No.1: The complainant availed service from the opposite parties and the complainant is a consumer of the opposite parties and the dispute is regarding the deficiency of service. Hence the complaint is maintainable before the Forum. Points 2 and 3: In order to prove the complainants case, the complainant adduced oral evidence as PW1. PW1 stated that his claim for reimbursement of medical expenses was repudiated by the opposite parties due to the reason that treatment was taken from NSS Medical Mission Hospital which is not an approved hospital of SAIL. The documents produced by PW1 are marked as Exts.A1 to A15. PW1 prays for allowing the complaint. The learned counsel for the opposite parties cross-examined PW1. At the time of cross examination, the book-let relating to the group medi-claim scheme for the year 2005 produced by the opposite parties is marked through PW1as Ext.B1. 4th page in Ext.B1 is marked as Ext.B1(a) and 15th page of Ext.B1, the list of approved hospitals by SAIL, the 32nd column stating the name of Christian Mission Hospital, Pandalam is marked as Ext.B1(c). The documents marked from the side of the complainant, Ext.A1 is the copy of covering letter sent along with the claim formto the opposite parties. Ext.A2 is the policy renewal certificate dated 27.01.2005. Ext.A3 is the recognition letter from Govt. of India, Ministry of Health stating the recognition of NSS Medical Hospital, Pandalam as per C.S. rules. Ext.A4 is the copy of letter sent to the opposite parties on 14.04.2006. Ext.A5 is the certificate of posting of Ext.A4. Ext.A6 is the copy of claim form sent on 9.01.2006. Ext.A7 is the medical bill for the treatment of complainant dated 26.12.2005. Ext.A8 is the copy of claim form of complainants wife dated 9.01.2006 sent to the opposite parties. Ext.A9 is the medical bills for the treatment of complainants wife. Ext.A10 is the copy of letter-dated 10.05.2006 sent to the opposite parties by the complainant. Ext.A11 is the Policy Renewal Certificate dated 13.02.2006. Ext.A12 is the copy of claim form dated 10.05.2006. Ext.A13 is the copy of medical bills for the treatment of the complainant. Ext.A14 is the copy of complainants wifes OPD claim form dated 10.05.2006. The relevant medical bill for Ext.A14 claim for is Ext.A15. The documents marked from the side of opposite parties, Ext.B1 is the booklet relating to the conditions of medi-claim policy agreement. Ext.B1(a) is the 4th page of Ext.B1 details regarding the OPD treatment and Ext.B1(b) is the 32nd coloumn, 15th page of Ext.B1 stating the name of Christian Mission Hospital approved by SAIL for the purpose of mediclaim insurance. On perusal of the evidence in this case, the complainant had lodged two claims for getting the medical expenses incurred for the treatment of him and his wife at NSS Medical Mission Hospital, Pandalam during the coverage of medi-claim insurance scheme. The contention of the opposite parties is that the medical bills for the treatment availed from NSS Medical Mission Hospital is not allowable that hospital is not approved by SAIL. The SAIL had prepared a list of hospitals from where the employees avail treatment for the purpose of medical reimbursement under this scheme. NSS Medical Mission Hospital is not a recognised hospital as per list by SAIL and the medical expenses for the treatment done in that hospital cannot be allowable. Ext.B1 the booklet containing the conditions and details of the medi-claim policy for the year 2005 had listed the approved hospitals for OPD treatment under SAIL medi=claim scheme. Ext.B1(b) stating the name of Christian Mission Hospital, Pandalam is an approved hospital by SAIL. It is pertinent to note that the opposite parties allowed the complainants claim of medical expenses for the treatment done at NSS Medical Mission Hospital upto 2005 even through it is not an approved hospital of SAIL. Medical expenses for the treatment done at NSS Medical Mission Hospital from 12.02.2005 to 26.12.2005 were allowed by the opposite parties. The repudiated claim is in respect of the medical bills from 2006. But as per Ext.B1(b), Christian Mission Hospital, Pandalam was approved by SAIL in the year 2005. The Christian Mission Hospital, Pandalam is very nearer to the NSS Medical Mission Hospital and from the residence of the complainant. The complainant can avail treatment from there as it is an approved hospital for this purpose. But the complainant failed to avoid treatment from an approved hospital Pandalam even after approving an hospital at Pandalam. Ext.A3, the letter from Govt. of India, Ministry of Health stating the recognition of NSS Medical Mission Hospital under CS (MA) Rules. The date of issuance of Ext.A3 is March 1987. Ext.B1 was published in the year 2005 and in Ext.B1, it is specifically stated the name of approved hospital by SAIL at Pandalam for the purpose of group medi-claim scheme. In this circumstance, we find no deficiency of service from the part of opposite parties and hence the complainants prayer is not allowable. In the result, this C.C. is dismissed. No costs. Declared in the Open Forum on this the 15th day of October, 2008. C. Lathika Bhai, (Member) Sri. Jacob Stephen (President) : Sri. N. Premkumar (Member) : Appendix: Witness examined on the side of the complainant: PW1 : K.R. Narayana Kurup. Exhibits marked on the side of the complainant: A1 : Photocopy of the letter dated 9.1.2006 along with two bills sent by the complainant to the additional second opposite party. A2 : Photocopy of the insurance renewal Certificate dated 27.1.2005. A3 : Photocopy of the letter issued by Ministry of Health & Family Welfare, Govt. of India to the Superintendent, NSS Medical Mission Hospital, Pandalam. A4 : Photocopy of the letter dated 12.4.2006 sent by the complainant to the additional second opposite party. A5 : Certificate of posting of Ext.A4 letter. A6 : Photocopy of OPD treatment claim form 9.1.2006. A7 : Photocopy of the cash bill dated 26.12.2005 for Rs.229-93 issued by NSS Medical Mission Hospital, Pandalam to the complainant. A8 : Photocopy of the OPD treatment claim form dated 9.1.2006. A9 : Photocopy of the cash bill dated 26.12.2005 for Rs.540-49 issued by NSS Medical Mission Hospital, Pandalam to the complainant. A10 : Photocopy of the letter dated 10.5.2006 along with two bills sent by the complainant to the additional second opposite party. A11 : Copy of the Insurance Renewal Certificate dated 13.2.2006. A12 : Photocopy of the OPD treatment claim form dated 10.5.2006. A13 : Photocopy of the cash bill dated 2.5.2006 for Rs.304-48 issued by NSS Medical Mission Hospital, Pandalam to the complainant. A14 : Photocopy of the OPD treatment claim form dated 10.5.2006. A15 : Photocopy of the cash bill dated 2.5.2006 for Rs.1858-68 issued by NSS Medical Mission Hospital, Pandalam to the complainant. Witness examined on the side of the opposite parties : Nil. Exhibits marked on the side of the opposite parties: B1 : Booklet containing the conditions of Group Mediclaim Scheme for the year 2005 for retired employees and their spouses. B1(a) : The relevant portion of Ext.B1 (page No.4). B1(b) : The relevant portion of Ext.B1 (page No. 15).