KERALA STATE CONSUMER DISPUTES REDRESSAL COMMISSION

VAZHUTHACAUD, THIRUVANANTHAPURAM

APPEAL No.235/2016

JUDGEMENT DATED: 23.10.2024

(Against the Order in C.C.No.20/2011 of CDRF, Thrissur)

PRESENT:

APPELLANT:

(by Adv. S. Reghukumar)

Vs.

RESPONDENTS:

(by Adv. Unnikrishnan V.)

JUDGEMENT

SRI. K.R. RADHAKRISHNAN :  MEMBER

          This is an appeal filed under Section 15 of the Consumer Protection Act, 1986 against the order in C.C.No.20/2011 on the file of the Consumer Disputes Redressal Commission, Thrissur (hereinafter referred to as the ‘District Commission’ for short).  As per the order dated 29.01.2016, the District Commission partly allowed the complaint directing the 1^st opposite party to pay an amount of Rs.5,550/-(Rupees Five Thousand Five Hundred and Fifty only) with 12% interest from the date of complaint within one month from the date of receipt of a copy of the order by the complainant.  It was further directed that after complying with the order, the 1^st opposite party can recover that amount from the 3^rd opposite party, who provides the insurance coverage.

          2.       The averments contained in the complaint in brief are as follows:  The complainant was a member of the insurance scheme provided to her family by the 1^st opposite party for reimbursement of medical expenses.  The 2^nd opposite party was the Third Party Administrator (TPA) and the 3^rd opposite party was the insurance company.  According to the complainant, the 1^st opposite party had taken a Group Insurance Policy which covered treatment expenses for the family members up to Rs.60,000/-(Rupees Sixty Thousand only).  She was admitted in Mother Hospital, Olarikkara for which she has incurred an expense of Rs.35,000/-(Rupees Thirty Five Thousand only).  However, the insurance company paid Rs.9,450/-(Rupees Nine Thousand Four Hundred and Fifty) only.  The complaint was filed by her claiming the balance amount of Rs.25,550/-(Rupees Twenty Five Thousand Five Hundred and Fifty only) with 12% interest and a compensation of Rs.10,000/-(Rupees Ten Thousand only) and costs.

          3.       The 1^st opposite party entered appearance and filed their version.  According to them, the 1^st opposite party is a Charitable Trust functioning for the poor people.  They had given the insurance premium for covering persons coming under BPL category in Nattika Constituency.  They had taken a Group Health Insurance Policy from the 3^rd opposite party and the scheme was implemented through the second opposite party, TPA.  The premium for the beneficiary was paid by the 1^st opposite party.   Apart from paying the insurance premium all other liabilities to pay the claims are with the other opposite parties.  The premium payable by the complainant was paid by the 1^st opposite party and no share was given by her for taking the Group insurance Policy.  As the liability to pay the claims are with other opposite parties, they are not liable to pay any amount to the complainant.  Hence, they sought for dismissal of the complaint.

          4.       The complainant filed proof affidavit and Exhibits P1 to P6 were marked on her side.  Her husband was examined as PW1 on her behalf.  The 1^st opposite party filed version and their officer was examined as RW1 and Exhibit R1 was marked on their behalf.  Opposite parties 2 and 3 did not appear before the District Commission despite receiving notice and hence they were declared ex-parte.  On the basis of the evidence adduced the District Commission passed the impugned order. The first opposite party challenges the said order. No appeal is filed by the other opposite parties.

          5.       Heard both sides. The learned counsel for the appellant submitted that they have given the insurance coverage free of cost to the beneficiary and the liability for payment of the claim is with the insurance company.  As per the scheme, the maximum amount payable for a single treatment is limited to Rs.15,000/- (Rupees Fifteen Thousand) and the insurance company has already paid Rs.9,450/-(Rupees Nine Thousand Four Hundred and Fifty).  The balance amount of Rs.5,450/- (Rupees Five Thousand Four Hundred and Fifty) should have been claimed from the insurance company and not from the appellant. The decision to allow or disallow a claim is taken by the second and third respondents and the appellant has no role in it.   Hence, the learned counsel prayed for allowing the appeal and exonerate the appellant from payment of the balance amount.

6.       The learned counsel for the first respondent submitted that the insured has spent an amount of Rs.35,000/-(Rupees Thirty Five Thousand only) towards the medical expenses for her treatment.  But the insurance company allowed only Rs.9,450/-(Rupees Nine Thousand Four Hundred and Fifty only) and she is entitled to get the balance amount. There is violation of policy provisions resulting in deficiency of service on the part of the opposite parties and hence they are liable to pay the balance amount. The appellant is equally liable as the policy is taken by them. The learned counsel prayed for dismissing the appeal.

7.       We have considered the submissions on both sides and perused the records.  The complaint has arisen out of a claim under ‘Janaraksha Manappuram Free Insurance Scheme’ sponsored by the Appellant/first opposite party.  The scheme was implemented in seven Panchayats of Nattika Constituency for those persons Below Poverty Line (BPL).  The scheme was implemented jointly with the RSBY scheme of the Central Government and UHI Scheme of the State Government.  The entire beneficiary premium was paid by the appellant/1^st opposite party.  No amount is collected from the first respondent.  As is evident from the brochure published in respect of the insurance scheme (Exhibit P6) the maximum amount payable under the scheme is Rs.60,000/-(Rupees Sixty Thousand only) for one year up to six members of the family.  The maximum amount payable under a single treatment is Rs.15,000/-(Rupees Fifteen Thousand only).  The complainant has already received Rs.9,450/-(Rupees Nine Thousand Four Hundred and Fifty only). 

8.       The 1^st respondent/complainant has not produced any communication from the insurance company regarding the break-up of the amount already paid to her.  Hence, the reasons for disallowing the balance amount cannot be ascertained.  Moreover, a per Exhibit P6 brochure it is clearly stated that it is an insurance scheme and the claims are payable by the insurance company and not by the appellant/1^st opposite party.  As they are only a facilitator for the scheme by paying the beneficiary share of the premium, they cannot be held liable to pay any claim under the policy.  The District Commission erred in finding deficiency in service on the part of the appellant/first opposite party and directing them to pay  the balance claim amount of Rs.5,550/-(Rupees Five Thousand Five Hundred and Fifty) with interest. Hence the order dated 29.01.2016 of the District Commission is liable to be set aside. 

9.       In the result, the appeal is allowed and the order dated 29.01.2016 in CC No 20/2011 of the District Commission is modified to the extent that the appellant/1^st opposite party is exonerated from paying the balance amount of
Rs.5,550/-(Rupees Five Thousand Five Hundred and Fifty only).  There shall be no order as to costs.

          The appellant has deposited an amount of Rs.4,400/-(Rupees Four thousand four Hundred  only) towards statutory deposit at the time of filing this appeal.  This amount shall be released to them on proper acknowledgement.

SL