Tamil Nadu

South Chennai

CC/67/2005

Sri Devi Hospital - Complainant(s)

Versus

National Insurance Company Ltd., - Opp.Party(s)

S.Vijayakumar

14 Feb 2017

ORDER

                                                                        Date of Filing :   08.10.2002

                                                                        Date of Order :   14.02.2017

DISTRICT CONSUMER DISPUTE REDRESSAL FORUM, CHENNAI (SOUTH)

     2^nd Floor, Frazer Bridge Road, V.O.C. Nagar, Park Town, Chennai-3

 

PRESENT: THIRU. S. PANDIAN, B.Sc., L.L.M.                       : PRESIDENT            

                  TMT. K.AMALA, M.A. L.L.B.,                                 : MEMBER I

            DR. T.PAUL RAJASEKARAN, M.A ,D.Min.PGDHRDI, AIII,BCS : MEMBER II          

C.C.NO.67/2005

TUESDAY THIS  14^TH  DAY OF FEBRUARY  2017

M/s. Sri Devi Hospital,

Rep. by its Director Dr. K. Senthilnathan,

1620A 16^th Main Road,

Anna Nagar,

Chennai 40                                                .. Complainant.

 

                        ..Vs..

1. The Senior Manager,

National Insurance Company Limited,

Division III,

751, Anna Salai,

Chennai -2.

 

2. The Personnel Manager,

M/s. Britannia Industries Ltd.,

M.T.H. Road,

Padi, Chennai – 50.

 

3. M/s. Brittania Employees Welfare Association,

Rep. by its Secretary,

M.T.H.Road,

Padi, Chennai 50.                                                       ..Opposite parties.

 

Counsel for the Complainant        : M/s. S.Vijayakumar  & another    

Counsel for the opposite party-1  : M/s. S.Vadivel & other

Counsel for the opposite party-2  : M/s. S.Ramasubramaniam & Associates

For the 3^rd opposite party            :  Exparte

 

ORDER

THIRU. S. PANDIAN, PRESIDENT

          This complaint has been filed by the complainant against the opposite parties under section 12 of the Consumer Protection Act 1986 seeking direction to pay the total sum of Rs.3,80,270.19 with interest and also to pay cost of the complaint.

1. The averment of the complaint are brief as follows:

        The complainant are running hospital in the name and the style of Sridevi Hospital, which is one of the leading hospital in Chennai.   In terms of the policy, the 1^st opposite party shall repay the cost sustained by the insured for the medical treatment during the period of policy.   The 2^nd opposite party in the course of the business and the welfare of the workmen had constituted a welfare association in the name of M/s. Britannia Industries Employees Welfare Association.  The 1^st opposite party had approached the 2^nd opposite party to insure its employees under the Group Insurance Scheme.   Consequently the 2^nd opposite party in the welfare of the employees joined in the Group insurance scheme by paying necessary premium for the employees.  The 1^st opposite party had issued policy in favour of the employees of the 2^nd opposite party vide policy No.500300/10/20/16.  In terms of the said policy, the 1^st opposite party shall reimburse the expenses incurred for the treatment meted out to the insured employees.  

2.     In continuation of the above, the complainant was approached by the opposite parties to render treatment to the employees under the said scheme.  The 1^st opposite party had entered into an agreement with the complainant along with the 2^nd opposite party for giving treatment to the employees referred to by the 2^nd opposite party.  The complainant in turn shall claim the bills from the 1^st opposite party after completion of the treatment.    As agreed by the complainant and both the opposite parties, the complainant had been treating the employees referred to be the 2^nd opposite party under the insurance policy.

3.     That on completion of the treatment, they used to raise the bills and the 1^st opposite party had been clearing the same.   The 1^st opposite party had cleared the claims made to number of employees on various dates as per the documents annexed hereto.   Based on the same, the complainant had given treatment to second opposite party employees viz 1) Ellappan, 2. Mr. Saravanan, 3) Munusamy, 4) Karuniasekar 5) Mani 6) Mr.Venkatesh 7) Mr.Ramesh, 8) Arunachalam 9) Vibu 10. Sampath 11) Madwai, 12)  Karunakaran 13) Thiruvengadam  and 14) Anbalagan on various dates for various ailments.   On discharge of the above said persons, the complainant had sent their claim for the services rendered to the opposite parties.  The first opposite party had received the claims and failed to clear the same immediately.  

3.     The complainant submits that the treatment was given to the said person under compelling and emergency situation.    The 1^st opposite party without application of mind had rejected the claims of the complainant causing great loss and hardship.  In reply to the rejections made by the 1^st opposite party , the complainant had sent letter on 9.7.2001 explaining the cause for claim and the relevant treatment meted out in all the individual cases.   Inspite of the same, the 1^st opposite party  failed to accept the claim of the complainant and refused to settle the charges.  

4.     Inspite of repeated reminders there was no response from the 1^st opposite party the complainant was compelled to issue an Advocate notice on 12.2.2002, calling upon the opposite parties to clear the dues.  In reply to the same the 1^st opposite party had alleged that they have followed with the policy conditions and based on the same the claims  were rejected.    In terms of the said insurance policy and subsequent agreement entered into with the complainant, the 1^st opposite party had availed the services of the complainant and failed to discharge its commitments which is a clear case of deficiency of service, the 1^st opposite party having received the premium from the 2^nd opposite party and promised the complainant to repay its claims failed to comply with its commitments and committed deficiency of service.  The act of the 1^st opposite party has caused great loss and hardship and also has caused mental agony.  Hence the complaint.

5. Written Version of 1^st opposite party is  in brief as follows:

        The 1^st opposite party denies all the allegations and averments contained in the complaint except those that are specifically admitted herein.   The complaint itself is not maintainable against the opposite party for the reason that there is no independent dealing by the 1^st opposite party with the complainant.   If at all the complainant had any grievance against the National Insurance Co. Ltd., the complainant ought to have laid their claim only against the National Co. Ltd.,  The Senior Manager in his individual capacity had nothing to do with the complainant.  According to the complainant it is purely a contract.   If at all any violations or contradictions in the terms and conditions of the contract, the complainant ought to have filed a suit.  

6.     The complainant stated that 1^st opposite party shall repay the costs sustained by the insured for the medical treatment during the period of policy only in the terms of policy.  So the complainant’s knows that this opposite party cannot do anything beyond the terms of the policy.  If at all the complainant is affected by the decision of the opposite party  the complainant ought to have filed a civil suit by producing valid evidence both oral and documentary evidence to substantiate their claim.  

7.     Those claims which were not satisfied and requirements of the terms and conditions of the policy would have been rejected by the opposite party.   During the relevant period the opposite party had disposed off all the claims of the complainant in accordance with the terms and conditions of the policy.   So it is not correct to say that this opposite party had received the claims  and failed to clear the  same immediately.  The averments that the 1^st opposite party without application of mind had rejected the claims of the complainant causing more loss and hardship is not correct.        The advocate notice issued by the complainant dated 12.2.2002 was suitably replied by this opposite party by reply dated 26.4.2002.   The Insurance company officials cannot go beyond the terms and conditions of the policy.    Hence there is o deficiency of service on the part of this opposite party.   

8. Written Version of 2^nd opposite party is  in brief as follows:

        The 2^nd opposite party deny various allegations and averments made in the complaint except those that are specifically admitted hereunder.  The complainant is not a consumer within the meaning of the Consumer Protection Act, since he has neither availed of any services from the opposite party, nor has paid any consideration to the opposite party and therefore the complaint is liable to be dismissed in limini against the opposite party.    On the complaint’s own admission disputed questions of fact have been raised and agitated which require detailed oral and documentary evidence and complicated question of fat are raised the parties are required to approach the civil court and the Consumer forum is not the appropriate forum to decide that mattes.  

9.     The 2^nd opposite party is a unnecessary party to the complaint since the contract of insurance as can be seen from the complaint itself is between the complainant and M/s. Brittania Industries Employees Welfare Association, Padi.  Whereas the complainant has impleaded the 2^nd opposite party company who is in no way concerned with the transaction mentioned in the complaint and therefore the 2^nd opposite party is an unnecessary party to the complaint and therefore the complaint is liable to be dismissed as against the 2^nd opposite party.  

10.    The 2^nd opposite party further submit that they neither have knowledge of either the contract entered into by M/s. Brittania Industries Employees Welfare Association, Padi with the 1^st opposite party M/s. National Insurance Company Limited, Division III, Chennai nor do they have any say in settling the medical claims of the complainant as called for in the complaint.   Therefore the impleading of the 2^nd opposite party is clearly an abuse of process of law and on this ground also the complaint should be dismissed as against the 2^nd opposite party.   It is false to state that the 2^nd opposite party had paid the premium for insuring purposes.   Therefore there exist no privity of contract between the complainant and the 2^nd opposite party and therefore would not bind the 2^nd opposite party in any manner.  

11.    The 2^nd opposite party denies having entered into an agreement as stated by the complainant.  The 2^nd opposite party is not being a party to the contract, they have no knowledge of either the contract entered into by the complainants with National Insurance Company Limited Divisions, III, Chennai neither do they have any say in settling the medical claims of the complainant.   The advocate’s notice was  received by the opposite party and detailed reply notice was sent denying the allegations.   Hence this complaint is liable to be dismissed.

 12.   Inspite of service of notice, the opposite party-3 is called absent and set exparte.

 

13.    In order to prove the averments of the complaint, the complainant has filed proof affidavit as his evidence and documents Ex.A1 to Ex.A16 marked.  Proof affidavit of 1^st and 2^nd opposite parties  filed and Ex.B1 to Ex.B14  marked on the side of the 1^st and 2^nd opposite parties.

14.   At this juncture, the point for the consideration before this

        Forum is:  

 

1.  Whether there is any deficiency of service on the part of the 

     Opposite parties as alleged in the complaint?

 

2. Whether the complainant is entitled to any relief as prayed for?

15. Point No.1:-

As per the case of the complainant is that, the complainant had given treatment to the 2^nd opposite party’s employees on various dates for various ailments and after discharge of the said employees when their claim for services rendered to the opposite party-1,  but the opposite party-1 failed to clear the claim made by the complainant immediately which caused great loss and hardship, the act of the opposite parties  amounts for deficiency of service and therefore this complaint is filed.

16.    Such being so, the contention raised by the 1^st opposite party is that they cannot go  beyond the terms and conditions of the policy and the opposite party while repudiating the claim made by the complainant valid reasons  were  assigned  and the same was duly communicated to the complainant and the 3^rd opposite party had not come forward in support of the claim made by the complainant  and he was remained exparte and the complainant failed to file the agreement entered between the parties for the reason best known to him and hence there is no deficiency in service on the part of the opposite party-1.

17.    In such circumstances on the side of the 2^nd opposite party it is contended that the complainant has no locus  stand to come before this Forum only  and further narrated the opposite party-2 is unnecessary party to the complaint, since there is no way concerned with the transaction mentioned in the complaint and in fact there is no agreement between the complainant and the opposite party-2 as stated in the complaint.   Therefore the opposite party -2 has no knowledge of the said contract and hence the 2nd opposite party is not liable to pay any compensation to the complainant.

18.    At the outset it goes without saying that the complainant is having bounden duty to prove the deficiency of service on the part of the opposite parties.   First of all on careful perusal of the averments of the complaint as well as the evidence adduced on the side of the complainant it is learnt that the complainant is one of the leading Hospital in Chennai and had given treatment continuously for the employees attached with the opposite party-2 company and the completion of the treatment of the complaint mentioned employees under the Group Insurance Scheme.    The complainant has claimed Rs.3,80,270.19   but the same has been rejected by the opposite party-1, unfortunately it is further seen that in spite of reply letters Ex.A1, Ex.A3 to Ex.A14 to the 1^st opposite party,  Ex.A2 letter received from opposite party-1, the opposite party-1 has failed to clear the claims of the treatment rendered by the complainant to 14 employees of the 2^nd opposite party.   It is further seen that the complainant with alternative issued a legal notice dated 12.2.2002 which is marked as Ex.A15 and the reply letter sent by the opposite party-1 by making some false averments which is marked as Ex.A16.   Furthermore the complainant stated that the 2^nd opposite party  being the company was paying the necessary premium for the employees in the Group Insurance Scheme to the 1^st opposite party and it is further stated that the repudiation of the claim by the opposite party-1 clearly amounts for deficiency of service which caused financial loss, hardship and mental agony to the complainant.

19.    On the other hand on going through  the evidence of the opposite party-1 it is stated that they have not negativated all the claims and only some of the claims have  been repudiated by the 1^st opposite party but as per the terms and conditions of the policy which are valid reasons and the same were duly communicated to the complainant.   Therefore there is no deficiency of service on the part of the opposite party.  Further the complainant is not a consumer under the Consumer Protection Act and there is no privity of contract between the complainant and the 1^st opposite party as alleged in the complaint and the complainant conveniently not filed the alleged agreement before this forum  and therefore the complaint is not at all maintainable.   The terms and conditions of the policy is marked as Ex.B1 and the repudiation letter with valid reason  sent to the complainant for the employees namely Mr. Ellappan, T. Saravanan, Mr. Munusamy, Mr. Mani, Mr. Venkatesh, Mr. K.Ramesh, Mr. Arunachalam, Mr. Vibu, Mr.Sampath,  Mr. Madurai, Mr. Karunakaran, Mr. Thiruvengadam, Mr. Anbazhagan which are marked as Ex.B2 to Ex.B14.

20.    In such circumstances on perusal of the evidence of the opposite party-2 it is elicited that it is not a necessary party, since there is no agreement between the opposite parties 1 & 2 and therefore the opposite party-2 have no knowledge about the said policy and in fact opposite party-3 association only taken the policy and paid the premium and therefore the employees of opposite party-2 is clearly an abuse of process of law.  Furthermore it is stated that there is exist no privity of contract between the complainant and the 2^nd opposite party and the 2^nd opposite party had nothing to do with the transaction mentioned in the notice and hence there is no question of deficiency of service on the part of the 2^nd opposite party.

21.    At this juncture, on careful perusal of the rival submission put forth on either side it is crystal clear from the averments of the complainant and evidence of the complainant that the employees come under the opposite party-3 association are working in the opposite party-2 company such situation as per the complainant’s averments, the opposite party-2 has taken Group Insurance Scheme for his employees by paying necessary premium for the employees and in the terms of the policy the opposite party-1 shall reimburse the expenses incurred for the treatment meted out to the  insured employees.    In this regard there is no serious objection on the side of the opposite party-1 and alleged policy No.500300/10/20/18 is not disputed by the 1^st opposite party.   It is further raised by the complainant that the 1^st opposite party had entered into an agreement with the complainant along with the 2^nd opposite party for giving treatment to the employees referred by the 2^nd opposite party and in turn the complainant shall claim the bills from the 1^st opposite party after completion of the treatment.   While being so both the opposite parties 1 & 2 had categorically  denied the alleged agreement entered with the complainant.   If it is so, it is the foremost duty of the complainant to prove the same on production of the said agreement before this forum.  But till the end of the trial the complainant has not chosen to file the alleged agreement entered  with the opposite parties 1 & 2.  Therefore the plea taken by the opposite parties 1 & 2 that there is no such agreement with the complainant and hence the complainant is conveniently failed to produce the same holds good and it cannot be thrown out easily. 

 

22.    From the above said facts it is needless to say that the averments made by the complainant in respect of the alleged agreement clearly goes out.  If  there is no such agreement,  how the complainant come forward to say that there is a deficiency of service on the part of the opposite parties 1 & 2 is in question.   

23.      The next point to be taken into consideration is whether the repudiation of the claim  of the complainant by the opposite party-1 is proper or not?  At the outset, as per the evidence adduced on the side of the opposite party-1 and the repudiation all the claims for 14 employees only as per the terms and conditions of Ex.B1 and the same has been duly informed to the complainant through Ex.B2 to Ex.B14.   In such circumstances though the complainant has not sent any reply letters Ex.A3 to A14 by stating that all the employees’  needs admission for proper cure on the severity of symptoms.  At the same time, on careful perusal of  Ex.B2 to Ex.B14, it has been noted that all the employees underwent treatment  with the complainant  does not warrant hospitalization and the investigation for the diagnosis could have been done have outpatient procedure and therefore refused as not claim.  In such circumstances in order to prove that all the employees undergone treatment as mentioned in the complaint warranted admission for the severity of disease, the complainant ought to have produced relevant documents before this forum but failed to do so.    Therefore, without any hesitation this forum, can say that the repudiation of the claim by the 1^st opposite party is proper as per the terms and conditions of the Ex.B1 policy.  

24.    Furthermore it is noticed that as rightly pointed out by the opposite parties 1 & 2 there is no privity of contract between the complainant and the opposite parties and the same has not been produced before this forum.  Moreover it is  pertinent to note that the 3^rd opposite party does not come forward in support of the claim made by the complainant even after they were impleaded as party in this proceedings but they remained exparte on such fact has to be taken into consideration.   Furthermore it is noted from the averments of the complainant that the 1^st opposite party is not at all repudiated of the claim made by the complainant.  But only some of the claims have been refused which are not come under the purview of the terms and conditions of the policy clearly reveals the facts that the opposite party-1 has acted properly.

25.    In the light of the above facts and circumstances, this forum has come to the conclusion  that there is no deficiency of service on the part of the opposite parties and the same also not been proved by the complainant through consistent evidence.  Thus point No.-1 is answered accordingly.

26.  Point No.2

          As per the view concluded in point No.1, the complainant is not entitled for any relief as prayed for in the complaint.  Thus the point No.2 is answered  also accordingly.

In the result, the complaint is dismissed.  No cost.

 

         Dictated by the President to the Assistant, taken down, transcribed and computerized by her, corrected by the President and pronounced by us in the open Forum on this the  14^th  day  of  February  2017.

 

MEMBER-I                        MEMBER-II                             PRESIDENT.

 

Complainant’s side documents:

Ex.A1-  9.3.2001   - Copy of letter by the complainant to the 1^st opposite party.                   

Ex.A2- 13.3.2001  - Copy of letter by the 1^st opposite party to complainant.                               

Ex.A3- 8.7.2001    - Copy of letter by the complainant to the 1^st opposite party.                     

Ex.A4- 8.7.2001    - Copy of letter by the complainant to the 1^st opposite party.

Ex.A5- 8.7.2001    - Copy of letter by the complainant to the 1^st opposite party.

Ex.A6- 9.7.2001    - Copy of letter by the complainant to the 1^st opposite party.

Ex.A7- 9.7.2001    - Copy of letter by the complainant to the 1^st opposite party.

Ex.A8- 9.7.2001    - Copy of letter by the complainant to the 1^st opposite party.

Ex.A9- 9.7.2001    - Copy of letter by the complainant to the 1^st opposite party.

Ex.A10-9.7.2001   - Copy of letter by the complainant to the 1^st opposite party.

Ex.A11- 9.7.2001  - Copy of letter by the complainant to the 1^st opposite party.

Ex.A12- 9.7.2001  - Copy of letter by the complainant to the 1^st opposite party.

Ex.A13- 9.7.2001  - Copy of letter by the complainant to the 1^st opposite party.

Ex.A14- 11.7.2001 – Copy of letter by the complainant to the 1^st opposite party.

Ex.A15- 12.2.2002         - Copy of legal notice.

Ex.A16- 26.4.2002 – Copy of reply from the 1^st opposite party to the

                               complainant

 

Opposite parties’ side document: -   

Ex.B1-         -       - Copy of terms and conditions of the policy.

Ex.B2= 20.3.2001 - Copy of letter by the 1^st opposite party to the complainant.

Ex.B3- 29.3.2001  - Copy of letter by the 1^st opposite party to the complainant.

Ex.B4- 12.3.2001  - Copy of letter by the 1^st opposite party to the complainant.

Ex.B5- 28.3.2001  - Copy of letter by the 1^st opposite party to the complainant.

Ex.B6- 29.3.2001  - Copy of letter by the 1^st opposite party to the complainant.

Ex.B7- 29.3.2001  - Copy of letter by the 1^st opposite party to the complainant.

Ex.B8- 29.3.2001  - Copy of letter by the 1^st opposite party to the complainant.

Ex.B9- 28.3.2001  - Copy of letter by the 1^st opposite party to the complainant.

Ex.B10-29.3.2001  - Copy of letter by the 1^st opposite party to the complainant.

Ex.B11- 28.3.2001         - Copy of letter by the 1^st opposite party to the complainant.

Ex.B12- 12.3.2001         - Copy of letter by the 1^st opposite party to the complainant.

Ex.B13- 28.3.2001         - Copy of letter by the 1^st opposite party to the complainant.

Ex.B14- 28.3.2001         - Copy of letter by the 1^st opposite party to the complainant.

 

 

MEMBER-I                        MEMBER-II                              PRESIDENT.