PRESENT:- Sri. K. Gheevarghese, M.A, L.L.B - President<br /> Smt. Saji Mathew, B.A, L.L.B - Member<br /> <br /> V. Kunhiraman, :<br /> Thazheveetil Veedu, : Complainant<br /> Aalattil P.O. :<br /> Wayanad. :<br /> <br /> <br /> 1. Manager, :<br /> Life India Children's Birthday fund :<br /> and Education project, Ernakulam. :<br /> :<br /> 2. Divisional Manager, :<br /> National Insurance Company, Aluva. : Opposite parties.<br /> :<br /> 3. Saleela Mani, Parakkadi, :<br /> Aalattil, Thalapuzha. :<br /> <br /> <br /> Complainant by : Sri. K.A. Johny, Advocate Kalpetta.<br /> Opposite party No. 1 by : Sri. C.K. Sajan and N.J. Hanas, Advocate Kalpetta.<br /> <br /> <br /> ORDER<br /> <br /> By Sri. K. Gheevarghese, President:<br /> <br /> <br /> The complaint filed under Section 12 of the Consumer Protection Act.<br /> <br /> <br /> The complaint in brief is as given below.<br /> <br /> The Complainant is a government employee. The 1st and 2nd Opposite Parties are instigators of a scheme called Life India Children's Birth Day Fund and Education Project III. The Opposite Party No.3 canvased the Complainant to join the scheme and as per which the Complainant was admitted on 27.06.2003. The first installment of Rs.500/- was given at the time of admission. According to the Opposite Parties, the scheme envisages reimbursement<br /> (Contd...... 2)<br /> - 2 -<br /> of the medical treatment expenses. Accordingly the condition requisites is that the member who belongs to scheme has to be admitted in a hospital at least for a day if the favour of the scheme to be received. The Opposite Party No.3 detailed all this benefits of scheme to the Complainant and he was influenced to join the scheme. On 25.09.2003 the Complainant was admitted in Amritha Institute of Medical Science and research Centre and discharged from the hospital on 26.09.2003. The bill amount towards the treatment Rs.2,103/- was remitted by the Complainant. The Complainant approached the Opposite Party No.2 in several occasions in order to get the favour of the scheme, however the Opposite Party No.2 denied the request of Complainant on the ground that the Complainant had not undergone any treatment in the hospital instead the admission in the hospital was only for the diagnostic tests. The medical check up cannot be treated as the part and parcel of the treatment. The Opposite Party No.2 was sent lawyer notice by the instruction of the Complainant and as a result the voucher with an inscription of Rs.2,103/- was sent to the Complainant but no amount was given. The other expenses and the interest of the amount spent for treatment was not given to the Complainant. The Opposite Parties acts are the absolute deficiency of service. The Opposite Parties are jointly and severally liable for the cost and compensation to<br /> the Complainant. The Complainant later filed petition before the Taluk Legal Services Authority, Mananthavady and the petition was called on 13.08.2005. The Opposite Parties were not ready to settle the matter. There may be a direction to the Opposite Parties to give the Complainant Rs.2,103/- towards the treatment expenditure with 20% interest. The other expenses include Rs.500/- towards notice charge and compensation of Rs.1,000/- and cost of the Complaint Rs.1,000/- are to be directed to be given to the complaint.<br /> <br /> The Opposite Party No.1 filed version on their appearance. The admission of the<br /> (Contd...... 3)<br /> - 3 -<br /> Complainant to the Life India Children's Birth Day Fund and Education Project III was effected on receiving Rs.500/- towards admission fee and Rs.5/- as membership fee, which was on 27.06.2003. The admission of the Complainant was in compliance with the terms and conditions offered the exclusion, exemption and other conditions of the scheme as inscribed in the overleaf of the application form and in the certificate. The membership was issued to the Complainant on agreeing the terms and conditions. The Opposite Party No.1 entered in to an agreement with M/S National Insurance Company Ltd Alway Divisional Office, Urumbath building, Pump Junction Alway. The Opposite Party No.2 has two personal accident Policies Janasuraksha and Janatha personal accident policies. The terms, conditions and limitation of the 2 Opposite parties are subjected to the amendments made by the GIC, TAC or Government of India from time to time. The person who is admitted to any one of the scheme the benefits of the scheme are governed by the terms and conditions. The brivity of contracts of the Complainant is only with the Opposite Party No.2. A person admitted to the scheme is bound by the terms and conditions. There is no cause of action against the Opposite Party No.1. More over the Opposite Party No.1 has not entered in to any contract or agreement with the Complainant. If the Complainant is found entitled for<br /> any amount towards the compensation or cost, the recovery of the same can be from the Opposite Party No.2 alone. The Opposite Party has not done any deficiency in service to the Complainant. The clause 7(k) and 7(L) in the overleaf of the application covers the terms and conditions in the agreement entered in to between the Opposite Parties No.1 and 2. These conditions are also stated on the front side of the certificate issued by the Opposite Party No.1 to the Complainant. The Opposite Party No.1 is arrayed only as a formal party in this complaint. If at all it is found that the Complainant is entitled for any amount regarding the claim that may be ordered to recover from the Opposite Party No.2. The Opposite Party No.1<br /> (Contd....... 4)<br /> - 4 -<br /> is not liable to compensate the Complainant. The petition is to be dismissed with cost to the Opposite Party No.1.<br /> <br /> The Opposite Parties No.2 and 3 did not file version, they are declared exparte.<br /> <br /> The points in consideration are:<br /> 1. Is there any deficiency in service on the part of the Opposite Parties?.<br /> 2. Who is responsible to provide the benefits of the insurance scheme?<br /> 3. <br /> 1.Reliefs and costs.<br /> <br /> Points No.1:<br /> The Complainant had not tendered any oral evidence apart from filing the documents. The Ext.A1 is the certificate issued to the Complainant. Ext.A2 is the receipt given to the membership fee. The Admission of the Complainant to the scheme is undisputed. The claim of the Complainant is rejected by the Opposite Party No.2. Letter sent to the Complainant with the specification with the claim is treated closed is marked as Ext.A3. The<br /> Complainant was admitted in the hospital on 25.9.2003 for evaluation of abdominal pain and nausea. Ext.A9 is the discharge summary given by the department of Gastroenterology. The clause in Ext.A9, course in hospital, shows that OGD scopy revealed pangastritis and the final diagnosis clause in the same exhibits reveals pangastritis neurodermatitis lateral epicondylitis. The Complainant entered in to an agreement with the Opposite Party No.2 through the Opposite Party No.1. The admission of the Complainant in the hospital is not disputed by the Opposite Parties. The claim was rejected upon the lame ground that the admission in the hospital was not for treatment instead, it was only for diagnostic tests. Even<br /> (Contd...... 5)<br /> - 5 -<br /> if, the terms and conditions of the Opposite Party No.2 is taken in to consideration. As per the Ext.A9, the Complainant is admitted in the hospital for a genuine ground of ailment and to avail treatment for the same. The Complainant claim was rejected by the Opposite Party No.2. The rejection of the claim by the Opposite Party No.2 is unreasonable and improper. The point No.1 is found against the Opposite Parties.<br /> <br /> Point No.2: <br /> The Opposite Party No.2 entered in to an agreement with the Opposite Party No.1 to cover the insurance of the person admitted by the Opposite Party No.1. The Opposite Party No.3 acted only as an agent. Any how Ext.A3 is a clear admission from the Opposite Party No.2 that they are the concerned to cover the risk of the insured. The Complainant's claim liability is shifted to the Opposite Party No.2. The Opposite Party No.2 is responsible to meet the claim of the Complainant.<br /> <br /> The point No.3:<br /> The Complainant is entitled for Rs.2,103/- the amount spent for the treatment in the<br /> hospital and with an interest of 12% from the date of filing this complaint till the payment. The Opposite Party No.2 has to give the Complainant is Rs.500/- towards the cost along with the compensation of Rs.1,000/- to the Complainant.<br /> <br /> In the result the Opposite Party No.2 is directed to give the Complainant Rs.2,103/- (Rupees Two thousand One hundred and Three only) along with 12% interest from the date of filing this complaint till the payment. The Compensation of Rs.1,000/- (Rupees One thousand only) and cost Rs.500/- (Rupees Five hundred only) also to be given to the<br /> <br /> Complainant within one month from the date of receiving this order. In case of any failure on the part of the Opposite Party No.2, the Complainant can execute this order according to the provisions of law.<br /> <br /> Pronounced in open Forum on this the 3rd day of January 2008.<br /> <br /> PRESIDENT:<br /> <br /> MEMBER:<br /> <br /> /True copy/<br /> <br /> PRESIDENT, CDRF WAYANAD.<br /> <br /> <br /> APPRENDIX<br /> <br /> Witnesses for the Complainant:<br /> <br /> Nil<br /> <br /> Witnesses for the Opposite parties<br /> <br /> Nil<br /> <br /> Exhibits for the Complainant:<br /> <br /> A1 <br />