DISTRICT CONSUMER DISPUTES REDRESSAL COMMISSION PALAKKAD

Dated this the 11^th  day of  January 2022

Present  :  Sri.Vinay Menon V., President        

             :   Smt.Vidya.A., Member

       Date of filing: 03.08.2017.

       CC/69/2017

Krishnakumar.M

S/o.Sivarama Menon (Late)                          -          Complainant      

Madathil veedu

Mathur Post

Palakkad

(By Adv:K.Rajan)

                              Vs

1.  Roopeshkumar P.M                              

     Medicare Insurance

      T.P.Services India (Pvt) Ltd

      3^rd Floor, Jomer Arcade

      Opp.G.H.S.S. (girls)

      Ernakulam (South)

      682 016

2.  Manager                                                      -         Opposite Parties

     SBI Kottayi Branch

     Palakkad 678 572

    (By Adv:K.Dhananjayan)                                                                                     

3.  Managing Director     Lakshmi Hospital

     Chittur Road

     Palakkad 678 572

    (By Adv:A.V.Ravi)

4.  The Manager

     SBI General Insurance

     N.S.Towers

     Near Stadium Bus Stand

     Coimbatore Road

     Palakkad-3

     (By Adv:P.Prasad)     

O R D E R

By Smt Vidya A, Member

1.Brief Facts of the Complaint

1.       The complainant is a policy holder under opposite party 1 and opposite party 2 with policy No.000000005677203 and State Bank of India G Health card holder with ID 2602848.  He was admitted for treatment in the 3^rd opposite hospital on 27/09/2016.  They did not accept the card as the policy had expired before that.  The complainant had renewed the policy in time by paying the amount with the 2^nd opposite party.  The complainant did not get the benefits under the policy because of the deficiency in service on the part of opposite party 1 and 2 and he suffered mental and financial difficulties because of this.  Even though he had submitted formal complaints to the 1^st and 2^nd  opposite parties he did not get any relief.

So this complaint is filed for getting compensation to the tune of Rs.1,00,000/- (Rupees One lakh only) and Rs.5,000/- (Rupees Five thousand only) as additional expenditure for the treatment.

2.       Complaint admitted and notice issued to the opposite parties.  The notice to the 1^st opposite party was served, but they did not appear before the forum and so they were set exparte. 2^nd and 3^rd opposite parties appeared and filed their version.  Later on after closing the evidence, the complainant filed IA.241/19 and IA.242/19 on 15/10/2019 to re-open evidence and implead supplemental opposite party 4.  It was allowed and opposite party 4 was impleaded.  They appeared and filed their version.

3.       Contentions of 2^nd opposite party’s version

The 2^nd opposite party is an unnecessary party in the complaint and the complainant has no case that there is any deficiency in service on their part.  The complainant had remitted an insurance premium of Rs.5,400/- (Rupees five thousand and four hundred only) and that has duly been credited to account as WDL TFR Insurance premium as on 27/07/2016.  Except this, this opposite party has not done anything in pursuance of the said policy.  The role of this opposite party is only to the extent of transfer of the insurance amount under the instruction of the complainant.  There is a no deficiency in service on their part and they are not liable to pay the amount claimed by the complainant.  So this complaint is to be dismissed with their cost.

4.       3^rd opposite party’s version

The complaint is false, frivolous and vexatious and they are unnecessary party in the complaint.  The complainant was admitted in the 3^rd opposite party’s hospital and he was treated there.  Except this, they are not aware of the details of the policy including the date of expiry and its renewal.  There is no deficiency in service on the part of 3^rd opposite party and there is no cause of action against them.  So this complaint is to be dismissed.

5.       Main contention in the version of the 4^th opposite party

The complaint is premature since the complainant failed to submit one of the  basic documents ie one cancelled cheque leaf to confirm the bank account details for the payment of claim amount. Though a copy of cheque was submitted, it read a different name Babu.M.K whereas, the policy records of the insured complainant read his name as Krishnakumar.M Hence it was practically impossible for the 4^th opposite party to pay the claim amount to that account.

If the complainant was particular on receiving the claim amount in the name Babu.M.K itself, instead of the name mentioned in the policy, a request should have been formally made as per the prescribed form, for an endorsement in the policy for name change.  Without which any financial institution will ask for KYC (Know Your Customer detail requirement under the law) like in this case. 

After observing the discrepancy in the document, opposite party1 on behalf of opposite party 4 wrote speaking letters informing the defects and requirement on 03/05/2017 and 13/05/2017.   However, the complainant did not bother to comply with the requirements.  The complainant had adequate time to revert and substantiate the account details, but he did not utilize it.  The opposite party has to verify the details of every payout especially in the wake of insurance fraud which are prevalent in the society.  The act of the opposite party calling for the clarification of payment details are prudent and judicious.

The opposite party is ready and willing to honor the claim amount for Rs.12,189/- (Rupees Twelve thousand one hundred and eighty nine only) under the policy subject to submission of document in view of the bills submitted for Rs.13,970/- (Rupees thirteen thousand nine hundred and seventy only).

The complainant failed to submit the necessary documents warranted for the claim settlement in the account details with actual name as in the policy.  There is no deficiency in service on the part of this opposite party and the complaint has to be dismissed with cost.

6.       Complainant filed chief affidavit along with documents.  Exhibit A1 to A4 marked (A1 in series). Opposite party 2 and opposite party 3 filed chief affidavit.  Exhibit B1 was marked from 2^nd opposite party’s side.  Later on supplemental opposite party was impleaded as per order IA.242/2019.  Opposite party-4 filed affidavit and Exhibit B2 to B6 marked from their part and Evidence closed. 

7.       Main points to be considered

          (1)Is there any deficiency in service on the part of opposite parties?

          (2)If so, what is the relief as to cost and compensation.

          Points 1 and 2

8.       We have perused the affidavit and documents produced from both sides.  It is clear from the contentions and documents produced from 4^th opposite party that they were ready to settle the complainant’s claim on production of necessary documents.

9.       Exhibit B2 is the copy of the cancelled cheque produced by the complainant before 4^th opposite party.  On perusal of the copy of the cheque and policy documents, it is  clear that the name written in the cheque is  Babu.M.K and the policy documents shows the name as ‘Krishna Kumar M’.  So the 4^th opposite party is completely justified in calling for the necessary documents for claim settlement.

          Exhibit B3 dated 03/05/2017 and Exhibit B4 dated 13/05/2017, the letters issued by opposite party 1 to the complainant calling for the document, a pre-printed cancel cheque of the proposer (KrishnaKumar.M) along with a mandate form mentioning account no, name and full address of the bank with IFSC and MICR code.  They have clearly mentioned the reason for requiring this additional document. 

          Further they have expressed their inability to settle the claim without this document and states that The closing of the claim does not restrict the insured from submitting the above mentioned documents, to enable us to re-open the case and proceed further

10.     The complainant did not furnish the necessary documents in order to enable them to settle the claim.  So no deficiency in service can be attributed to the opposite parties 1 and 4.        

11.     All through the trial, the complainant tried to prove that Babu.M.K. and Krishna Kumar M are one and the same person. No one has a case that ‘Krishnakumar M’ is not  Babu.M.K. The only case is that the complainant has not issued relevant documents for facilitating transfer of funds by the 4^th opposite party.  The 4^th opposite party  contended in their affidavit that if the complainant was particular on receiving the claim amount in the name Babu.M.K. itself, instead of name mentioned in the policy, it could have been done on a request made in the prescribed form, for an endorsement in the policy for name change.

12.     It is evident that the complainant did not do anything in furtherance of his claim settlement, even though 4^th opposite party was ready to honor his claim amount.  So there is no deficiency in service on the part of opposite party 4^th & 1^st  opposite parties.

13.     Further opposite party 2^nd and 3^rd opposite parties are unnecessary parties and they were unnecessarily impleaded in the complaint and dragged before the commission.  The complainant is bound to compensate 2^nd and 3^rd opposite parties for that. In the result the complaint is dismissed.  The complaint being one arising out of the adamancy and whims of the complainant, rather than a bonafide grievance, we direct the complainant to pay 3,000/- (Rupees Three thousand only) each to opposite parties 1 to 4 by way of costs.

          The complainant is at liberty to submit the necessary documents before the 4^th opposite party and claim the amount offered by them.

          Order shall be complied within a period of 45 days from the receipt

          of the order.         

    Pronounced in the open court on this the 11^th  day of  January 2022.

                                                                                   Sd/-                                          

                                                                                         Vinay Menon V

                                              President.

                                                                                                 Sd/-                                          

                                                                                               Vidya.A                                                                                                       Member

Exhibits marked on the side of complainant

Ext. A1- Discharge bill issued by OP3 dated 01/10/2016.

Ext.A2 -  Discharge summary issued by OP3 dated 01/10/2016.

Ext.A3 -  Copy of SBI general Insurance card .

Ext.A4 -  Copy of certificate issued by OP2 dtd 23/02/2017.  

Exhibits marked on the side of Opposite parties

Ext. B1– Statement of account of the complainant from 01/06/2016 to

    31/03/2017 issued by  OP2.

Ext. B2- Copy of cancelled cheque in the name Babu M.K.

Ext. B3-  Copy of letter addressed to the complainant by the third party

     administrator dtd 03/05/17

Ext. B4-  Copy of letter addressed to the complainant by the  third party

               administrator dtd 13/05/17

Ext. B5 - Copy of bill issued by OP3 dtd 01/10/2016.

Ext. B6 -  Copy of SBI general Insurance policy bearing no.5677203-01  dtd

     12/08/2017.

 Cost: 12,000/-

NB: Parties are directed to take back all extra set of documents submitted in the proceedings in accordance with Resolution 20(5) of the Consumer protection (Consumer Commission Procedure) Regulations, 2020 falling which they will be weeded out.