BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM

VAZHUTHACAUD : THIRUVANANTHAPURAM

PRESENT:

SHRI. G. SIVAPRASAD : PRESIDENT

SMT. BEENA KUMARI. A : MEMBER

SMT. S.K. SREELA : MEMBER

C.C. No: 25/2007 Filed on 22/1/2007

Dated: 31..03..2010

Complainants:

1. Consumer Protection Council of Kerala, Reg.No.T.198/1985, Represented by its General Secretary, Smt. Annie Jacob No.153, A.K.G Nagar, Peroorkada, Thiruvananthapuram – 695 005.

    

2. Employees Provident Fund Pensioners’ Association Kerala (Reg.No.T.210/97) Represented by its Secretary, C.V. Gopinathan Nair, Saroja Bhavan, Devaswam Lane, Kesavadasapuram, Pattom Palace – P.O., Thiruvananthapuram – 695 004.

(By Advs. K.G.M Nair & Narayan. R)

Opposite parties:

1. Oriental Insurance Company Ltd., Represented by its Senior Divisional Manager, Divisional Office No.1, Jeevan Vihar Buildings, 4^th Floor, Sansad Marg, New Delhi – 110 001.

   (By Adv. G.S. Kalkura)

2. The Central Provident Fund Commissioner, EPFO Head Quarters, Bhavishya Nidhi Bhavan, 14 Bhikaji Cama Place, New Delhi – 110 066.

3. The Regional Provident Fund Commissioner, Pattom, Thiruvananthapuram – 695 004.

(2^nd & 3^rd opp. Parties by Adv. K. Ramachandran Nair)

This O.P having been heard on 24..12..2009, the Forum on 31..03..2010 delivered the following:

ORDER

SMT. S.K.SREELA, MEMBER:

The grievance of the consumers are as follows: The members of the Employees Provident Fund Pensioners Association are retired employees of the Employees Provident Fund Organization. All these members and their spouses are beneficiaries of the Medi-claim Scheme of the 1^st opposite party. As per Clause 6 of the said policy, retired employees are entitled to get medical aid benefits including reimbursement of expenses incurred for medical treatment and hospitalization. The 2^nd opposite party was paying substantial amount as premium to the 1^st opposite party on behalf of the retired employees, and the 3^rd opposite party is given charge of forwarding to the 1^st opposite party the particulars of members entitled to get benefits. However, some of the members of the 2^nd complainant association have not been given the due benefits of medical insurance in spite of having been enrolled in the policy and assigned valid PIN (Personal Identification Number). Repeated requests and reminders on the part of the members directly, and the 2^nd complainant association collectively, to the opposite parties have evoked no fruitful response so far. The delay caused in settling the claims by the opposite parties amounts to deficiency of service as defined in the Consumer Protection Act, 1986. Thus the complainants have been constrained to approach this Forum seeking redressal of their grievances.

2. The 1^st opposite party remain exparte and opposite parties 2 & 3 have filed their detailed version contending as follows: The Medical Insurance Scheme was instituted by the Central Board of Trustees, Employees Provident Funds Employees’ PF Organisation, as a welfare scheme, with a view to extend post retirement medical cover to its retired employees as a result of an agreement entered into by the Organisation with M/s. Oriental Insurance Company. The Group mediclaim policy was introduced with effect from 6/12/1994. Under the Group Mediclaim policy the Insurance premium was paid by the CBT, EPF and not by the individual pensioners and medical reimbursement were allowed on mutually agreed terms. The benefit of medi-claim policy was not available for the retired employees of the organisation during the period 6/12/1996 to 23/6/1998 due to certain anomalies in the medi-claim scheme of the Oriental Insurance Company. However, for the said period, the medical benefits were extended to the retired employees of the Organisation in the shape of medical reimbursement by the Department. The Oriental Insurance Company has appointed M/s. Genins India Ltd.as a third party administrator in accordance with the IRDA stipulations for providing cahsless service to the pensioners. Therefore, M/s. Genins India Ltd., the third party administrator is responsible for providing service like treatment and reimbursement of the hospital charges incurred by the insured persons. The liability of the EPF Organisation was only to keep the medi-claim policy alive by paying the renewal premium and same was renewed up to 23/10/2006. As per the Mediclaim Scheme the claimants have to send the claims under the policy to the 1^st opposite party within 30 days (90 days with effect from 1/3/2005) from the date of completion of the treatment. It is the responsibility of the 1^st opposite party to settle the claims as per the terms and conditions of the agreement. Since the 1^st opposite party, the 3^rd party administrator appointed the 1^st opposite party and the claimants are the only parties involved in the process of mediclaim, the other two opposite parties have no role in the process except in the cases of the death of the insured. In such cases the reimbursement allowed by the 1^st opposite party is released through the third opposite party. However, when some complaints regarding non-payment/delay in payment have been brought to the notice of the third opposite party, the matter was taken up with the 1^st opposite party for immediate redressal. All possible steps were taken up by these opposite parties for early reimbursement.

3. PW1 has been examined on behalf of the complainant and Exts. P1 to P4 were marked on their side. On the part of the opposite parties 2 & 3 DW1 has been examined and marked Exts. D1 & D2.

From the contentions raised following issues arise for consideration:

1. Whether there is any deficiency in service on the part of opposite parties?

2. If the above is in affirmative, from whom the complainants are entitled for relief claimed in the complaint?

3. Reliefs and costs?

5. Points (i) to (iii) : The allegations in the complaint are that the members mentioned in the complaint have been denied benefits of medical insurance in spite of having been enrolled in the policy and assigned PIN. The 1^st opposite party – the Insurance Co. remains exparte. Opposite parties 2 & 3 contend that the 1^st opposite party has appointed M/s. Genins India Limited as a third party administrator in accordance with the IRDA stipulations for providing cashless service to the pensioner and therefore the said 3^rd party administrator is responsible for providing service like treatment and reimbursement of the hospital charges incurred by the insured persons. Further it is contended that medi-claim policy was not available for the retired employees during the period 6/12/1996 to 23/6/1998 but the same was reintroduced with effect from 24/6/1998 and renewed year to year basis upto 23/6/02 that due to some administrative reasons further renewal from 24/6/2002 was not approved by the Govt and later the policy was renewed with effect from 4/10/2002. Further they have contended that the claims received from the retired employees of the organisation for the period from 24/6/2002 to 3/10/2002 were reimbursed by the organisation.

6. As per the complaint, the pensioners listed have claimed reimbursement for the period during 2006. DW1 has deposed that ’ഈ

case – ല്‍ claim settle ചെയ്തിട്ടില്ല എന്ന് പറഞ്ഞാല്‍ ശരിയാണ് ? 1^st opposite party യുടെ ഭാഗത്ത് നിന്ന് deficiency of service ഉണ്ടായി എന്ന്ബോദ്ധ്യപ്പെട്ടതുകൊണ്ടാണ് 1^st opposite party-യെ discharge ചെയ്യുകയും 24/10/2006 മുതല്‍ CSMA Medical Rules - ന്‍െറ കീഴില്‍ കൊണ്ട് വരികയും ചെയ്തത് .

7. The opposite parties 2 & 3 though argued that the complaint is bad for jon-joinder of necessary party for M/s. Genins India Limited has not been impleaded, it is to be noted that the pensioners do not have any direct dealings with this Genins India Limited and moreover they have not been appointed by the pensioner but by the Insurance Co. It is an internal matter between the Insurance Co. and the Genins India Limited wherein the pensioners have no involvement. Furthermore DW1 has deposed that ’1^st opposite party - യുടെ ഭാഗത്ത് നിന്നും deficiency in service ഉണ്ട് എന്ന് 2^nd & 3^rd opposite parties - ന് ബോദ്ധ്യപ്പെട്ടിട്ടുണ്ട്. അതുകൊണ്ടാണ് 24/10/2006 – മുതല്‍ 1^st opposite party – യെ disengage ചെയ്യുകയും mediclaim settle ചെയ്യുന്നതിന് Rules - ല്‍ കൊണ്ട് വന്നതും ’. DW1 has further admitted that the claim of the pensioners in this case have not been settled. Though DW1 has deposed that they have initiated proceedings against 1^st opposite party for not settling the claims, no evidence has been adduced to corroborate the same. He had deposed that communication was sent from head quarter for which also no document has been produced by opposite parties 2 & 3.

8. In the above circumstance, we hereby allow the complaint. The members mentioned in the complaint are found entitled for refund of the expenses, incurred for treatment, from the 1^st opposite party with 9% interest from the date of claim of each claimant till realisation. From the above discussions we are of the view that the pensioners listed below are found entitled for refund of the respective amount with 9% interest from the date of claim of each claimants, as follows: Shri. Sekharan Nair (PIN 00041), Rs.12,749.12/- with 9% interest from 24/5/2006, Smt. Gouri Menon (PIN 00588), Rs.11,000/- with 9% interest from 10/2/2006, Smt. B. Sarasamma (PIN 03593), Rs. 18,246/- with 9% interest from 8/6/2006, Shri. M.V. Poulose (PIN 00030), Rs.26,412/- with 9% interest from 24/4/2006, Shri. K.R. Revindranathan Nair (PIN 00175), Rs.21,768/- with 9% interest from 1/9/2006, Smt. Padmavathi Thankachchi (PIN 00176), Rs. 23,208/- with 9% interest from 15/9/2006, Shri. K. Gangadharan (PIN 02541), Rs. 16,983/- with 9% interest from 31/5/2005, Shri. K.P. Varunny (claiming on behalf of wife Santha Varunny (PIN 00620), Rs. 1,05,148/- with 9% interest from 28/8/2006 and Rs. 38,564/- with 9% interest from 27/10/06 (two claims), Smt. P.N. Assyamma (PIN 02930), Rs. 9,193.97/- with 9% interest from 26/6/2006 and Rs. 18,538.97/- with 9% interest from 28/06/2006 (two claims) and Smt. V. Bhagawathy (PIN 0054), Rs. 12,354/- with 9% interest from 23/9/2006.

Since interest has been ordered, there is no separate order as to compensation. The opposite parties shall also pay Rs.2,500/- to the complainants towards costs of the proceedings.

A copy of this order as per the statutory requirements be forwarded to the parties free of charge and thereafter the file be consigned to the record room.

Dictated to the Confidential Assistant, transcribed by her, corrected by me and pronounced in the open Forum, this the 31^st day March, 2010.

S.K. SREELA, MEMBER.

G. SIVAPRASAD,

PRESIDENT.

BEENA KUMARI.A, MEMBER.

ad.

C.C.No.25/2007

APPENDIX

I. Complainants’ witness:

PW1 : C.V. Gopinathan Nair

II. Complainants’ documents:

P1 : Copy of the Medi claim scheme of the 1^st opposite party

P2 : Copy of claim application preferred by each affected member

P3 : Copy of letter issued by the Regional Provident Fund Commissioner (HRM) bearing No.HRM- V/12(7)2005-06/OIC/renewal dated 23/2/06.

P4 : Copy of letter No.HRM-V/12(2)2004 from 2^nd opposite party dated 9/10/2006.

III. Opposite parties’ witness:

DW1 : K. Parameswaran

IV. Opposite parties’ documents:

D1 : Copy of letter dated 3/8/04 of the Central Provident Fund Commissioner.

D2 : Copy of detailed instruction issued by the Central Provident Fund Commissioner vide letter dated 18/10/06.

PRESIDENT

ad.

BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM

VAZHUTHACAUD : THIRUVANANTHAPURAM

PRESENT:

SHRI. G. SIVAPRASAD : PRESIDENT

SMT. BEENA KUMARI. A : MEMBER

SMT. S.K. SREELA : MEMBER

C.C. No: 25/2007 Filed on 22/1/2007

Dated: 31..03..2010

Complainants:

1. Consumer Protection Council of Kerala, Reg.No.T.198/1985, Represented by its General Secretary, Smt. Annie Jacob No.153, A.K.G Nagar, Peroorkada, Thiruvananthapuram – 695 005.

    

2. Employees Provident Fund Pensioners’ Association Kerala (Reg.No.T.210/97) Represented by its Secretary, C.V. Gopinathan Nair, Saroja Bhavan, Devaswam Lane, Kesavadasapuram, Pattom Palace – P.O., Thiruvananthapuram – 695 004.

(By Advs. K.G.M Nair & Narayan. R)

Opposite parties:

1. Oriental Insurance Company Ltd., Represented by its Senior Divisional Manager, Divisional Office No.1, Jeevan Vihar Buildings, 4^th Floor, Sansad Marg, New Delhi – 110 001.

   (By Adv. G.S. Kalkura)

2. The Central Provident Fund Commissioner, EPFO Head Quarters, Bhavishya Nidhi Bhavan, 14 Bhikaji Cama Place, New Delhi – 110 066.

3. The Regional Provident Fund Commissioner, Pattom, Thiruvananthapuram – 695 004.

(2^nd & 3^rd opp. Parties by Adv. K. Ramachandran Nair)

This O.P having been heard on 24..12..2009, the Forum on 31..03..2010 delivered the following:

ORDER

SMT. S.K.SREELA, MEMBER:

The grievance of the consumers are as follows: The members of the Employees Provident Fund Pensioners Association are retired employees of the Employees Provident Fund Organization. All these members and their spouses are beneficiaries of the Medi-claim Scheme of the 1^st opposite party. As per Clause 6 of the said policy, retired employees are entitled to get medical aid benefits including reimbursement of expenses incurred for medical treatment and hospitalization. The 2^nd opposite party was paying substantial amount as premium to the 1^st opposite party on behalf of the retired employees, and the 3^rd opposite party is given charge of forwarding to the 1^st opposite party the particulars of members entitled to get benefits. However, some of the members of the 2^nd complainant association have not been given the due benefits of medical insurance in spite of having been enrolled in the policy and assigned valid PIN (Personal Identification Number). Repeated requests and reminders on the part of the members directly, and the 2^nd complainant association collectively, to the opposite parties have evoked no fruitful response so far. The delay caused in settling the claims by the opposite parties amounts to deficiency of service as defined in the Consumer Protection Act, 1986. Thus the complainants have been constrained to approach this Forum seeking redressal of their grievances.

2. The 1^st opposite party remain exparte and opposite parties 2 & 3 have filed their detailed version contending as follows: The Medical Insurance Scheme was instituted by the Central Board of Trustees, Employees Provident Funds Employees’ PF Organisation, as a welfare scheme, with a view to extend post retirement medical cover to its retired employees as a result of an agreement entered into by the Organisation with M/s. Oriental Insurance Company. The Group mediclaim policy was introduced with effect from 6/12/1994. Under the Group Mediclaim policy the Insurance premium was paid by the CBT, EPF and not by the individual pensioners and medical reimbursement were allowed on mutually agreed terms. The benefit of medi-claim policy was not available for the retired employees of the organisation during the period 6/12/1996 to 23/6/1998 due to certain anomalies in the medi-claim scheme of the Oriental Insurance Company. However, for the said period, the medical benefits were extended to the retired employees of the Organisation in the shape of medical reimbursement by the Department. The Oriental Insurance Company has appointed M/s. Genins India Ltd.as a third party administrator in accordance with the IRDA stipulations for providing cahsless service to the pensioners. Therefore, M/s. Genins India Ltd., the third party administrator is responsible for providing service like treatment and reimbursement of the hospital charges incurred by the insured persons. The liability of the EPF Organisation was only to keep the medi-claim policy alive by paying the renewal premium and same was renewed up to 23/10/2006. As per the Mediclaim Scheme the claimants have to send the claims under the policy to the 1^st opposite party within 30 days (90 days with effect from 1/3/2005) from the date of completion of the treatment. It is the responsibility of the 1^st opposite party to settle the claims as per the terms and conditions of the agreement. Since the 1^st opposite party, the 3^rd party administrator appointed the 1^st opposite party and the claimants are the only parties involved in the process of mediclaim, the other two opposite parties have no role in the process except in the cases of the death of the insured. In such cases the reimbursement allowed by the 1^st opposite party is released through the third opposite party. However, when some complaints regarding non-payment/delay in payment have been brought to the notice of the third opposite party, the matter was taken up with the 1^st opposite party for immediate redressal. All possible steps were taken up by these opposite parties for early reimbursement.

3. PW1 has been examined on behalf of the complainant and Exts. P1 to P4 were marked on their side. On the part of the opposite parties 2 & 3 DW1 has been examined and marked Exts. D1 & D2.

From the contentions raised following issues arise for consideration:

1. Whether there is any deficiency in service on the part of opposite parties?

2. If the above is in affirmative, from whom the complainants are entitled for relief claimed in the complaint?

3. Reliefs and costs?

5. Points (i) to (iii) : The allegations in the complaint are that the members mentioned in the complaint have been denied benefits of medical insurance in spite of having been enrolled in the policy and assigned PIN. The 1^st opposite party – the Insurance Co. remains exparte. Opposite parties 2 & 3 contend that the 1^st opposite party has appointed M/s. Genins India Limited as a third party administrator in accordance with the IRDA stipulations for providing cashless service to the pensioner and therefore the said 3^rd party administrator is responsible for providing service like treatment and reimbursement of the hospital charges incurred by the insured persons. Further it is contended that medi-claim policy was not available for the retired employees during the period 6/12/1996 to 23/6/1998 but the same was reintroduced with effect from 24/6/1998 and renewed year to year basis upto 23/6/02 that due to some administrative reasons further renewal from 24/6/2002 was not approved by the Govt and later the policy was renewed with effect from 4/10/2002. Further they have contended that the claims received from the retired employees of the organisation for the period from 24/6/2002 to 3/10/2002 were reimbursed by the organisation.

6. As per the complaint, the pensioners listed have claimed reimbursement for the period during 2006. DW1 has deposed that ’ഈ

case – ല്‍ claim settle ചെയ്തിട്ടില്ല എന്ന് പറഞ്ഞാല്‍ ശരിയാണ് ? 1^st opposite party യുടെ ഭാഗത്ത് നിന്ന് deficiency of service ഉണ്ടായി എന്ന്ബോദ്ധ്യപ്പെട്ടതുകൊണ്ടാണ് 1^st opposite party-യെ discharge ചെയ്യുകയും 24/10/2006 മുതല്‍ CSMA Medical Rules - ന്‍െറ കീഴില്‍ കൊണ്ട് വരികയും ചെയ്തത് .

7. The opposite parties 2 & 3 though argued that the complaint is bad for jon-joinder of necessary party for M/s. Genins India Limited has not been impleaded, it is to be noted that the pensioners do not have any direct dealings with this Genins India Limited and moreover they have not been appointed by the pensioner but by the Insurance Co. It is an internal matter between the Insurance Co. and the Genins India Limited wherein the pensioners have no involvement. Furthermore DW1 has deposed that ’1^st opposite party - യുടെ ഭാഗത്ത് നിന്നും deficiency in service ഉണ്ട് എന്ന് 2^nd & 3^rd opposite parties - ന് ബോദ്ധ്യപ്പെട്ടിട്ടുണ്ട്. അതുകൊണ്ടാണ് 24/10/2006 – മുതല്‍ 1^st opposite party – യെ disengage ചെയ്യുകയും mediclaim settle ചെയ്യുന്നതിന് Rules - ല്‍ കൊണ്ട് വന്നതും ’. DW1 has further admitted that the claim of the pensioners in this case have not been settled. Though DW1 has deposed that they have initiated proceedings against 1^st opposite party for not settling the claims, no evidence has been adduced to corroborate the same. He had deposed that communication was sent from head quarter for which also no document has been produced by opposite parties 2 & 3.

8. In the above circumstance, we hereby allow the complaint. The members mentioned in the complaint are found entitled for refund of the expenses, incurred for treatment, from the 1^st opposite party with 9% interest from the date of claim of each claimant till realisation. From the above discussions we are of the view that the pensioners listed below are found entitled for refund of the respective amount with 9% interest from the date of claim of each claimants, as follows: Shri. Sekharan Nair (PIN 00041), Rs.12,749.12/- with 9% interest from 24/5/2006, Smt. Gouri Menon (PIN 00588), Rs.11,000/- with 9% interest from 10/2/2006, Smt. B. Sarasamma (PIN 03593), Rs. 18,246/- with 9% interest from 8/6/2006, Shri. M.V. Poulose (PIN 00030), Rs.26,412/- with 9% interest from 24/4/2006, Shri. K.R. Revindranathan Nair (PIN 00175), Rs.21,768/- with 9% interest from 1/9/2006, Smt. Padmavathi Thankachchi (PIN 00176), Rs. 23,208/- with 9% interest from 15/9/2006, Shri. K. Gangadharan (PIN 02541), Rs. 16,983/- with 9% interest from 31/5/2005, Shri. K.P. Varunny (claiming on behalf of wife Santha Varunny (PIN 00620), Rs. 1,05,148/- with 9% interest from 28/8/2006 and Rs. 38,564/- with 9% interest from 27/10/06 (two claims), Smt. P.N. Assyamma (PIN 02930), Rs. 9,193.97/- with 9% interest from 26/6/2006 and Rs. 18,538.97/- with 9% interest from 28/06/2006 (two claims) and Smt. V. Bhagawathy (PIN 0054), Rs. 12,354/- with 9% interest from 23/9/2006.

Since interest has been ordered, there is no separate order as to compensation. The opposite parties shall also pay Rs.2,500/- to the complainants towards costs of the proceedings.

A copy of this order as per the statutory requirements be forwarded to the parties free of charge and thereafter the file be consigned to the record room.

Dictated to the Confidential Assistant, transcribed by her, corrected by me and pronounced in the open Forum, this the 31^st day March, 2010.

S.K. SREELA, MEMBER.

G. SIVAPRASAD,

PRESIDENT.

BEENA KUMARI.A, MEMBER.

ad.

C.C.No.25/2007

APPENDIX

I. Complainants’ witness:

PW1 : C.V. Gopinathan Nair

II. Complainants’ documents:

P1 : Copy of the Medi claim scheme of the 1^st opposite party

P2 : Copy of claim application preferred by each affected member

P3 : Copy of letter issued by the Regional Provident Fund Commissioner (HRM) bearing No.HRM- V/12(7)2005-06/OIC/renewal dated 23/2/06.

P4 : Copy of letter No.HRM-V/12(2)2004 from 2^nd opposite party dated 9/10/2006.

III. Opposite parties’ witness:

DW1 : K. Parameswaran

IV. Opposite parties’ documents:

D1 : Copy of letter dated 3/8/04 of the Central Provident Fund Commissioner.

D2 : Copy of detailed instruction issued by the Central Provident Fund Commissioner vide letter dated 18/10/06.

PRESIDENT