BEFORE THE CONSUMER DISPUTES REDRESSAL FORUM,
SOUTH GOA AT MARGAO
Coram: Shri Jayant S. Prabhu, President
Ms. Savita G. Kurtarker, Member
Ms. Cynthia A. Colaco, Member
Complaint No. 74/2013
Mr. Suresh K. Raikar,
Kamakshi Vihar, 145 G/1,
Fatima Colony,
Alto, Dabolim Goa ….. Complainant
V/s.
1. National Insurance Company Ltd.,
(A Govt. of India Undertaking)
Divisional Office: 24, 2 & 3,
Central Market, 1st Floor,
West Punjabi Bagh,
New Delhi 110 026
2. The Zuari Holdings Ltd.,
Jai Kisaan Bhawan,
Zuarinagar Goa 403 726 ….. Opposite Parties
Complainant in person
Adv. R.M. Lotlikar for the Opposite Party No.1
Adv. A. Prabhugaokar for Opposite Party No.2
Complaint filed on 24/10/2013 Complaint disposed on 26/02/2015
O R D E R
(Per Ms. Savita G. Kurtarker, Member)
This Order shall dispose of the Complaint filed by the Complainant under section 12 of the Consumer Protection Act 1986.
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The brief facts of the case are as under:
- The Complainant is covered under Group Health Insurance Scheme of M/s. Zuari Holdings Ltd. i.e. Opposite Party No.2 in the present complaint. The Complainant has been paying his Family’s GHI premium to M/s. Zuari Holdings Ltd., Zuarinagar for over three decades.
- The wife of the Complainant was hospitalized at Kamakshi Arogya Dhama, an ayurvedic hospital at Shiroda Goa on 02.08.2012 due to acute spondylosys and she was discharged on 04.08.2012. The Complainant incurred expenditure amounting to Rs. 2,282/-.
- On 09.08.2012 the Complainant duly filled in claim form and submitted to Opposite Party No.2 for onward submission to Opposite Party No.1.
- On 08.11.2012 the Opposite Party No.2 informed the Complainant that the claim of the Complainant is repudiated by Opposite Party No.1and on same day the Complainant obtained written intimation rejecting his claim from Opposite Party No.2.
- The Opposite Party No.1 vide its letter bearing no. 361000 dated 16.10.2012 stated that the disease does not require hospitalization.
- Hence the present complaint with a relief that the Complainant be awarded a sum of Rs. 1,00,000/- towards expenses on hospitalization, litigation expenses, mental stress and agony caused to the Complainant and compensation.
- The Complainant filed the following xerox copies of the documents:
- Group Health Insurance claim for Rs. 2,282.00 dated 09.08.2012.
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- GHI Claim repudiation letter No. 361000 dated 16.10.2013 pertaining to claim No. 361000/46/12/85/90000513.
- Attending doctor Dr. Viraj Manerikar’s certificate certifying that the wife of the Complainant did require hospitalization.
- Registered Notice dated 26.09.2013 sent to OP No.1 and OP No.2.
- Registered A/D card signed by OP No.2.
- Registered A/D card signed by OP No.1.
- The Opposite Parties were served. Both the OPs filed their written version.
- The Opposite Party No.1 in his written version raised the objection that the complaint does not disclose any cause of action to file the present complaint before this Forum.
- The Opposite Party No.1 denied all the averments made in the complaint and prayed that the complaint may be dismissed.
- The Opposite Party No.2 filed his written version raising the following preliminary objections:
- The complaint is not maintainable against Opposite Party No. 2 under law as well as on the facts of the complaint and therefore same to be dismissed as against Party No.2.
- There is no cause of action against Opposite Party No.2.
- Opposite Party No.2 is neither a proper party nor a necessary party to determine the matter in controversy.
- The complaint against Opposite Party No.2 is not maintainable under the provisions of section 12 of Consumer Protection Act,1986.
- The Opposite Party No.2 in his written version denied all the averments made in the complaint and prayed that the complaint against the Opposite Party No.2 be dismissed as it is ex-facie erroneous and perverse.
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- All the parties filed their Affidavits-in-evidence so also written arguments.
- We have gone through the complaint, written version, affidavit –in-evidence and the written submissions of all the parties. We heard Complainant Shri Suresh Raikar together with ld. Advocate R.M. Lotlikar for OP1 and ld. Advocate A. Prabhugaokar for OP2.
- It is pertinent to note that the complaint is filed in the name of Shri Suresh Raikar who is the Complainant. It has been observed that the Complainant was not hospitalized, however we found that his wife Mrs. Smita Raikar was hospitalized. We have also observed that Mrs. Smita Raikar wife of the Complainant has not authorized Shri Suresh Raikar who filed the present complaint.
- We do agree that the Complainant is covered under Group Health Insurance Scheme with M/s. Zuari Holdings Ltd., Zuarinagar and regularly been paying GHI premium to M/s. Zuari Holdings Ltd., Zuarinagar i.e. Opposite Party No.2. However we do not find any averment in the complaint stating that the Complainant Shri Suresh Raikar has been authorized by his wife to file the present complaint. We also find no averment in the complaint that the Complainant Shri Suresh A. Raikar is entitled to file the present complaint on behalf of his wife. Therefore we have no hesitation to agree with the arguments advanced by ld. advocates for Opposite Parties that Mr. Suresh Raikar has no locus standi to file the present complaint and Mr. Suresh Raikar cannot be termed as a consumer under Consumer Protection Act 1986.
- During the proceedings of the present complaint the Complainant Shri Suresh Raikar filed an Affidavit-in-evidence of the Complainant in the name of his wife Smt. Smita Raikar. Meantime the Complainant Shri Suresh Raikar filed an application to correct
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typographical error committed by him in his complaint stating that instead of typing the name as Smita Raikar as Complainant has typed name as Suresh Raikar. Therefore the name of Shri Suresh Raikar be deleted and Smita Raikar be added to it.
18. Both the Opposite Parties vehemently objected to the correction. The Opposite Parties relied upon the decision of the Hon’ble National Consumer Disputes Redressal Commission, New Delhi in Revision Petition 3801 of 2011 in case of Ram Niwas Soni V/s. The Principal, Vaish Model Sr. Sec. School and ors. In the said decision Hon’ble National Commission held that the complaint filed by the Complainant on behalf of his major son without any authorization was not maintainable as the Complainant did not fall within the purview of consumer. In view of above findings, application filed by the Complainant was dismissed.
19.While perusing the evidence on record, we have also observed that Opposite Party No.2 has covered all the employees under Group Health Insurance Scheme, their spouses and two number of children till the age of 25 years who are insured and covered by the scheme for various elements and sickness as may be permissible under the scheme.
20.The Opposite Party No.2 is contributing 50% of the premium towards its employees including that of Complainant, his wife and children till the age of 25 years. The Opposite Party No.2 is purely a facilitator whose scheme is devised and operative by the Opposite Party No.1 extending the medical benefits to the employees and their family members.
21. It is not disputed that the Complainant submitted mediclaim to the Opposite Party No.2 on 09.08.2012 for onward submission to the National Insurance Company. i.e. Opposite Party No.1. Therefore we find no deficiency of service and unfair trade practice against Opposite Party No.2.
22.We have observed from the letter dated 16.10.2012 at Annexure 02 of the complaint that the claim of the Complainant is closed on account of the peril/cause of loss not covered in the policy and also on account of disease does not require hospitalization.
23. We have observed that there is no piece of evidence before us by way of Affidavit-in-evidence to convince us that the wife of the Complainant required hospitalization for acute spondylisis. We find at Annexure 03, page 22 of this file one certificate from one doctor Viraj M. Manerkar on quarter page of paper under the heading “to whomsoever it may concern” wherein it is stated that the patient was treated for panchkarma treatment. However, we could not consider this certificate as piece of evidence that Complainant was required to admit in the hospital for the acute cervical spondylosis as the said certificate which is on the piece of paper does not bear stamp and seal and also is not on the letter head of Kamakshi Arogyadham Hospital wherein the wife of the Complainant was admitted. The doctor which has given the certificate does not state that the wife of the Complainant has been under his treatment at Kamashi Arogyadham Ayurvedic Hospital at Shiroda Goa or he had treated her. So also we find the said Dr. Viraj M. Manerkar is not a doctor from the hospital where the Complainant’s wife was treated. Therefore we cannot accept the said certificate of the doctor Viraj M. Manerikar to support the case of the Complainant.
24.Under the circumstances we are of the opinion that the present complaint is not maintainable on facts and in law and also relying on the decision of the Hon’ble National Commission in Rev. Petition No. 3801 of 2011 in Ram Niwas Soni Vs. The Principal, Vaish Model Sr. Sec. School, we therefore pass the following order:
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O R D E R
The complaint is dismissed with no orders as to cost.
(Shri Jayant S. Prabhu)
President
(Ms. Savita G. Kurtarker)
Member
(Ms. Cynthia A. Colaco)
Member
pf:
27/2
