By Smt. C.S. Sulekha Beevi, President,

1. All the above cases are similar. Opposite parties and issues involved are the same. Hence they are considered together and disposed by this common order. These cases were originally disposed by my predecessor. On appeal filed by first opposite party the cases were remanded for fresh disposal after taking necessary steps for impleading proper parties. Thus second opposite party was impleaded. Version was filed by opposite parties. Evidence was adduced by both sides and the respective counsels were heard.

2. Facts:-

The complainant (O.P.320/2000) (Annamma Joseph) registered her name and availed membership under first opposite party by paying Rs.500/- as premium. She was assured that she would receive upto Rs.5,000/- as medical beneits under the Group Insurance Policy conducted through second opposite party. From 20-4-2000 till 02-5-2000 she was admitted and treated as inpatient due to typhoid in Nirmala hospital, Edakkara. She then preferred a claim for medical benefits along with necessary documents. For long time there was no response from opposite party. Later on enquiries she came to know that her claim is repudiated. She went to Manjeri branch of opposite party and requested to return the medical bills. But her request was declined. Hence this complaint praying for Rs.5,000/- as benefits under policy and for compensation of Rs.1,500/-.

3. O.P.321/2000

The complainant (Kunhathu.C.) took membership with first opposite party by paying Rs.500/- as premium. She was assured that she would receive upto Rs.5,000/- as medical benefits under the Group Insurance Policy. From 14-3-2000 till 19-3-2000 she was admitted and treated as inpatient due to pnuemonia in Nirmala Hospital, Edakkara. She then preferred a claim along with necessary documents. For long time there was no response from opposite party. Later on 09-8-2000 she received information that her claim is repudiated. She went to the Manjeri branch of opposite party three times and requested to return the hospital bills. Her request was declined. Hence this complaint claiming Rs.5,000/- as benefits under policy and Rs.3,000/- as costs.

4. O.P.322/2000

The complainant (Saliha) took membership with first opposite party by paying Rs.500/- as premium. She was assured that she would receive Rs.5,000/- as medical benefits under the Group Insurance Policy conducted through second opposite party. From 30-4-2000 till 03-5-2000 she was admitted and treated as inpatient due to typhoid, in Nirmala Hospital, Edakkara. She then preferred a claim for medical benefits along with necessary documents. Later she was informed that the claim is repudiated by the Insurance Company. She went to the Manjeri branch and requested to return the documents and medical bills. Her request was declined. Hence this complaint claiming Rs.5,000/- as benefits under policy and Rs.2,000/- as compensation.

5. O.P.323/2000

The complainant (Princy) took membership under first opposite party by paying Rs.500/- as premium. She was assured that she would receive Rs.5,000/- as medical benefits under the Group Insurance Policy conducted through second opposite party. She was admitted and treated as inpatient for typhoid, from 20-4-2000 till 03-5-2000 in Nirmala Hospital, Edakkara. She preferred a claim for medical benefits. Later opposite party repudiated her claim. She went to the Manjeri branch office and requested to return the hospital bills and other documents submitted by her. Opposite party declined the request. Hence this complaint claiming for Rs.5,000/- as benefits under the policy and Rs.1,500/- as compensation..

6. Fresh version was filed by first opposite party after the remand of the case separately in each case. It is submitted that first opposite party is a public charitable trust and is a corporate agent of second opposite party. Thus first opposite party had taken a Janarogya Bhima Master Policy with second opposite party by executing an agreement with second opposite party to the benefit of the members of the Trust. The insurance benefits will be available, to the members from second opposite party under the strength of the agreement. Complainants had paid Rs.500/- and availed membership subscription. That complainants are insured for mediclaim benefit upto Rs.5,000/- and for the benefit of the accident insurance scheme upto Rs.25,000/-. That complainants had preferred claim to the second opposite party and later first opposite party received letters repudiating the claims for the reason that the claims are not bonafide. That first opposite party is not a party to the dispute and claims are to be disbursed by the Insurance Company subject to terms and conditions of the policy. That the premium paid was forwarded to second opposite party. It is stated that the terms and conditions of the policy are recited at the over leaf of the signed application form filed by complainant for taking membership. The liability solely lies upon second opposite party. That there is no deficiency in service on the part of first opposite party.

7. Second opposite party who was impleaded after remand of the case filed separate version in each case. Second opposite party admits issuing the Group Insurance Policy in favour of first opposite party undertaking to cover the risk of the members. That the liability of opposite party to indemnify and provide medical benefits are strictly limited to the terms and conditions and limitations mentioned in the policy. It is stated that on enquiry made by opposite party after getting the claim revealed that the complainants have not taken any treatment as inpatient from Nirmala Hospital, Edakkara as averred in the complaint and that no amount was spend by them for treatment. That the averments with respect to illness, admission in the hospital as inpatient are false. The documents produced in support of the claim are concocted. That opposite party rightly repudiated the claims for the reason that the claims did not come within the purview of the policy agreement and because the claim was based on false and fabricated documents. This was informed to the complainants. That there is no deficiency in service and complainants are not entitled to any reliefs.

8. Evidence consists of the proof affidavit of complainants filed separately in each case and Exts.A1 and A2 marked for each complainant. Opposite party No.1 filed counter affidavit. Opposite party No.2 filed separate counter affidavit. Witness on behalf of second opposite party was examined as DW1 in O.P.320/2000. The evidence of DW1 adduced in O.P.320/2000 was adopted by both sides to all the other three cases. Thus, certified copy of the deposition of DW1 is placed in the other three similar matters. Ext.B1 marked in O.P.320/2000.

9. Points for consideration:-

(i) Whether opposite parties have committed deficiency in service.

(ii) If so reliefs and costs.

10. Point(i):-

It is not disputed that complainants are covered under the Group Insurance Policy. The main ground raised by Opposite party No.2 for dishonouring the claim is that the claim is false and the documents are fabricated. Each of the complainants have produced Ext.A1 and A2 which is the policy schedule and the treatment certificate. The treatment certificate is issued by Dr. Jalaja of Nirmala Hospital, Edakkara. Opposite party challenged the veracity of the treatment certificate and this doctor was summoned by second opposite party. She was examined as DW1. The doctor categorically deposed that the certificate were issued by her and that the complainants were treated in her hospital as inpatients during the period stated in the certificates. She admitted her signature in each of these document. Opposite party had sought direction through the summons to the doctor to be present along with relevant hospital records regarding the treatment given to each complainant. The doctor did not produce the treatment records. She offered explanation tot he effect that because the hospital building collapsed she had to shift the hospital to another building in January, 2006. That during such shifting she lost some of the hospital records and furniture. This explanation for non-production of records is reasonable and believable. In the treatment certificate issued the doctor has stated the period during which complainants were admitted and also the name of the disease for which they undertook treatment. DW1 has also deposed that no one from the Insurance Company has made any enquiries to her. The evidence tendered by DW1 has only supported the consistent case of complainants. Though opposite parties contend the claim of complainants to be false there is absolutely no evidence to support their submission. It is proved and established that second opposite party has repudiated the claim without any basis. Such repudiation is deficiency in service. It is second opposite party who has to honour the claim. Hence we find second opposite party deficient in service.

11. Point (ii):-

The amount payable as medical benefits to each complainant is Rs.5,000/-. The complainants have not produced any medical bills. It was submitted on behalf of the complainants that the medical bills and documents were given to first opposite party who had initially forwarded these documents along with claim application to second opposite party. This is admitted by opposite party No.1 in para 7 of the version filed before the remand of these cases (ie., on 24-11-2000). It is stated by first opposite party that on getting the claim intimation from complainants, first opposite party had forwarded the connected papers to second opposite party. Complainants had filed separate petitions in each case seeking direction against first opposite party to produce the medical bills and documents submitted by them. These petitions were allowed and first opposite party was directed to produce the documents called for by the complainant. On 31-8-2009 first opposite party filed affidavit in each case stating that complainants had never handed over the originals of medical bills related to hospitalization. But first opposite party has failed to state as to what were the documents submitted by complainants to first opposite party. It is also the case of complainants that when they received information that the claim is denied they went to the branch office of opposite party at Manjeri and requested to return the medical bills. Second opposite party has not specifically controverted in the counter affidavit that they did not receive any medical bills along with the claim applications submitted by complainants. Moreover the reason for repudiation stated in the letter of repudiation issued by second opposite party is that the claim is repudiated as being not bonafide. This letter does not say that the claim is repudiated for the absence of medical bills. In the affidavit filed by second opposite party in I.A.308/2009 (in O.P.323/2000) which is a petition to receive the version condoning the delay in filing version, second opposite party has stated in para 3 as under:

"This opposite party was not in the party array till recently. Only in this year this opposite party was served with a notice from this Forum calling upon the company to appear and submit the version. Since the claim is made on the basis of action arose about 10 years and no claim was preferred before this opposite party, this opposite party could not make any enquiry with regards to the genuine ness of the claim. Even then with a bonafide intention this opposite party made enquiries after getting notice from this forum and found that the claim is made on a wrong notion and the complainant is not entitled to get amounts as claimed in the complaint."

12. These affirmations are totally contradictory to the case set up by second opposite party that they made enquiries regarding the claim and found it to lack bonafideness and hence repudiated the claim. We have no hesitation to conclude that complainants had produced medical bills and all relevant documents necessary to process the claim at the time of submitting the claim. Hence the complainant cannot be deprived of the benefits for the only reason of absence of medical bills. From the above discussions we are constrained to conclude that each complainant is entitled to Rs.5,000/- as medical benefits under the policy. They are also entitled to interest @ 6% per annum from the date of complaint till payment which we consider would be adequate compensation for the illegal retainment of legitimate amount. Second opposite party who is the insurer is liable to pay the amount. First opposite party is exonerated from liability. We also consider that each complainant is entitled to cost of Rs.1,000/- which shall also be paid by second opposite party.

13. We appreciate the earnest work of counsel Smt. Jaya Madhduraj who appeared on behalf of the complainant in O.P.321/2000, O.P.322/2000 and O.P.323/2000, who was appointed as Legal aid on request made by complainants in these cases. We fix her remuneration/fee as Rs.500/- in each of the three cases. This amount will be paid to the counsel from the Legal aid benefit fund on her making an application for the same.

14. In the result we allow each of the above complaints and order that second opposite party shall pay to each complainant Rs.5,000/- (Rupees five thousand only) along with 6% interest per annum from date of complaint till payment together with cost of Rs.1,000/- (Rupees one thousand only) to each complainant within one month from the date of receipt of copy of this order.

 

Dated this 6th day of October, 2009.

Sd/-

C.S. SULEKHA BEEVI, PRESIDENT

Sd/-

MOHAMMED MUSTAFA KOOTHRADAN, Sd/-

MEMBER E. AYISHAKUTTY, MEMBER

APPENDIX

O.P..No.320/2000

Witness examined on the side of the complainant : Nil

Documents marked on the side of the complainant : Ext.A1and A2

Ext.A1 : Treatment certificate given by Dr. Jalaja, Nirmala Nursing Home, Edakkara

to complainant.

Ext.A2 : Photo copy of the Children's Birthday Fund & Educational Project Schedule

given by first opposite party to complainant.

Witness examined on the side of the opposite parties : DW1

DW1 : Dr. K. Jalaja, D/o K. Madhavan Nair(late), Nirmala Hospital, Edakkara.

Documents marked on the side of the opposite parties : Ext.B1

Ext.B1 : Photo copy of the Janarogya Bhima Master Policy Agreement between

second and first opposite parties.

O.P..No.321/2000

Witness examined on the side of the complainant : Nil

Documents marked on the side of the complainant : Ext.A1and A2

Ext.A1 : Photo copy of the Children's Birthday Fund & Educational Project Schedule

given by first opposite party to complainant.

Ext.A2 : Treatment certificate given by Dr. Jalaja, Nirmala Nursing Home, Edakkara

to complainant.

Witness examined on the side of the opposite parties : DW1

DW1 : Dr. K. Jalaja, D/o K. Madhavan Nair(late), Nirmala Hospital, Edakkara.

Documents marked on the side of the opposite parties : Ext.B1

Ext.B1 : Photo copy of the Janarogya Bhima Master Policy Agreement between

second and first opposite parties.

O.P..No.322/2000

Witness examined on the side of the complainant : Nil

Documents marked on the side of the complainant : Ext.A1and A2

Ext.A1 : Photo copy of the Children's Birthday Fund & Educational Project Schedule

given by first opposite party to complainant.

Ext.A2 : Treatment certificate given by Dr. Jalaja, Nirmala Nursing Home, Edakkara

to complainant.

Witness examined on the side of the opposite parties : DW1

DW1 : Dr. K. Jalaja, D/o K. Madhavan Nair(late), Nirmala Hospital, Edakkara.

Documents marked on the side of the opposite parties : Ext.B1

Ext.B1 : Photo copy of the Janarogya Bhima Master Policy Agreement between

second and first opposite parties.

O.P..No.323/2000

Witness examined on the side of the complainant : Nil

Documents marked on the side of the complainant : Ext.A1and A2

Ext.A1 : Photo copy of the Children's Birthday Fund & Educational Project Schedule

given by first opposite party to complainant.

Ext.A2 : Treatment certificate given by Dr. Jalaja, Nirmala Nursing Home, Edakkara

to complainant.

Witness examined on the side of the opposite parties : DW1

DW1 : Dr. K. Jalaja, D/o K. Madhavan Nair(late), Nirmala Hospital, Edakkara.

Documents marked on the side of the opposite parties : Ext.B1

Ext.B1 : Photo copy of the Janarogya Bhima Master Policy Agreement between

second and first opposite parties.

Sd/-

C.S. SULEKHA BEEVI, PRESIDENT

Sd/-

MOHAMMED MUSTAFA KOOTHRADAN, Sd/-

MEMBER E. AYISHAKUTTY, MEMBER