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: 108/2007 Filed on 25/4/2007

Dated: 31..03..2010

Complainants:

1. P. Suseela, Suprabhath, T.C.IV/591, S-1, Sree Vilas Lane, Kowdiar – P.O., Thiruvananthapuram – 695 003.

    

2. C.K. Prabhatha Chandran Nair, Suprabhath of ..do....

(By Adv. 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)

    

4. M/s. Genins India Ltd., Represented by its Managing Director, D-60, Sector-2, Noida – 201 301, Uttar Pradesh

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 allegations in the complaint are the following: The 1^st complainant is a retired employee of the 3^rd opposite party, Regional Provident Fund Commissioner's Office, Pattom, Thiruvananthapuram. The 2^nd complainant is the husband of the 1^st complainant. All retired employees of the Provident Fund Commissioner's office 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 and their spouses 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. The complainants were also granted the PIN number by the opposite parties, which is essential for making and settling all insurance claims. An amount of Rs. 12,071.48/- was spend towards the treatment of the 2^nd complainant; Rs. 3,443.81/- at Jubilee Hospital and an amount of Rs.8,627.67/- at Sree Chitra Institute of Medical Sciences. Thereafter on 15/10/2006, the 2^nd complainant submitted the claim forms with all documents of medical treatment incurred, for reimbursement of expenses incurred, to the 4^th opposite party. For long there was no response from the opposite parties. The delay caused in settling the claims by the opposite parties amounts to deficiency of service. In the communication issued by the Regional Provident Fund Commissioner (HRM) dated 23/02/2006, it has been brought to the attention of the complainants that the 2^nd & 3^rd opposite parties have decided to cease the medi-claim facility operated through the 1^st opposite party from 23/10/2006. That is, any expenses incurred by retired employees of the 3^rd opposite party organisation and their spouses for hospitalization on or after 24/10/2006, will not be borne by the 1^st opposite party. Even after the expiry of the term, the complainants' pending applications dated 15/10/2006 have not yet been honoured. Under the said circumstance there is a fear that the opposite parties are not keen in settling the claim of the complainants. Thus the complainants have been constrained to approach this Forum seeking redressal of their grievances.

2. Opposite parties 1 & 4 remain exparte.

3. Opposite parties 2 & 3 filed their 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 is paid by the CBT, EPF and not by the individual pensioners and medical reimbursement are 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 Co. 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 cashless 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 upto 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 submission and processing of claims for reimbursement are carried out by the claimants and 1^st opposite parties, the 2^nd & 3^rd opposite parties have no role in the process other than the case in which the insured has expired. In such cases the reimbursement allowed by the 1^st opposite party is released through the 3^rd opposite party. However, when some complaints regarding, the non-payment/delay in payment have been brought to the notice of the 3^rd 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.

4. PW1 has been examined on behalf of the complainants and Exts. P1 to P9 were marked. DW1 has been examined on behalf of opposite parties 2 & 3 and Exts. D1 & D2 were marked.

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 grievance pleaded in the complaint is that the complainants have not been provided with medical reimbursement inspite of having been enrolled in the policy and assigned valid PIN (Personal Identification Number). Opposite parties 2 & 3contend 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. The opposite parties 2 & 3 admit that during the period between 9/6/2003 and 8/9/2005, the medi-claim scheme under the 1^st opposite party was in operation and the medi-claim policy was kept alive by the 2^nd & 3^rd opposite parties.

6. The witness for the opposite party who has been examined as DW1 has deposed that ഈ case – ലെ complainants ന്‍െറ claim നാളിതുവരെ settle ചെയ്തിട്ടില്ല . 1^st opposite party – യുടെ ഭാഗത്ത് deficiency ഉണ്ടായി എന്നറിഞ്ഞുകൊണ്ടാണ് നിങ്ങള്‍ അവരെ disengage ചെയ്യുകയും 24/10/2006 മുതല്‍ CSMA Rules - ന് കീഴില്‍ engage ചെയ്യുകയും ചെയ്തത് (Q) അതെ (A). 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.

In the result, complaint is allowed. The complainants are entitled for refund of the claim amount with 9% interest from the date of claim till realisation. Hence the 1^st opposite party is directed to refund Rs.12,071.48/- with 9% interest from 15/10/2006 till realisation. Since interest has been ordered, there is no separate order as to compensation. The opposite parties shall also pay a cost of Rs.2,500/- to the complainants. Time for compliance 2 months.

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.108/2007

APPENDIX

I. Complainants' witness:

PW1 : P. Suseela

II. Complainants' documents:

P1 : Copy of the medi claim scheme

P2 : Copy of communication evincing the appointment of M/s. Genins India Ltd as TPA

P3 : Copy of medical bills of 2^nd complainant.

P4 : Copy of claim form dated 15/10/06 of the expenses incurred at Jubilee Hospital.

P5 : Copy of claim form dated 15/10/2006 of the expenses incurred at Sree Chitra Institute of Medical Sciences.

P6 : Copy of the letter sent by the 1^st complainant dated 22/12/06.

P7 : Copy of the letter dated 27/1/2007.

P8 : Communication issued by the Regional Provident Fund Commissioner (HRM) dated 23/2/2006.

P9 : 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 dt. 3/8/04 issued by the Central PF Commissioner.

D2 : Copy of detailed instructions issued by the Central PF Commissioner vide 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: 108/2007 Filed on 25/4/2007

Dated: 31..03..2010

Complainants:

1. P. Suseela, Suprabhath, T.C.IV/591, S-1, Sree Vilas Lane, Kowdiar – P.O., Thiruvananthapuram – 695 003.

    

2. C.K. Prabhatha Chandran Nair, Suprabhath of ..do....

(By Adv. 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)

    

4. M/s. Genins India Ltd., Represented by its Managing Director, D-60, Sector-2, Noida – 201 301, Uttar Pradesh

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 allegations in the complaint are the following: The 1^st complainant is a retired employee of the 3^rd opposite party, Regional Provident Fund Commissioner's Office, Pattom, Thiruvananthapuram. The 2^nd complainant is the husband of the 1^st complainant. All retired employees of the Provident Fund Commissioner's office 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 and their spouses 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. The complainants were also granted the PIN number by the opposite parties, which is essential for making and settling all insurance claims. An amount of Rs. 12,071.48/- was spend towards the treatment of the 2^nd complainant; Rs. 3,443.81/- at Jubilee Hospital and an amount of Rs.8,627.67/- at Sree Chitra Institute of Medical Sciences. Thereafter on 15/10/2006, the 2^nd complainant submitted the claim forms with all documents of medical treatment incurred, for reimbursement of expenses incurred, to the 4^th opposite party. For long there was no response from the opposite parties. The delay caused in settling the claims by the opposite parties amounts to deficiency of service. In the communication issued by the Regional Provident Fund Commissioner (HRM) dated 23/02/2006, it has been brought to the attention of the complainants that the 2^nd & 3^rd opposite parties have decided to cease the medi-claim facility operated through the 1^st opposite party from 23/10/2006. That is, any expenses incurred by retired employees of the 3^rd opposite party organisation and their spouses for hospitalization on or after 24/10/2006, will not be borne by the 1^st opposite party. Even after the expiry of the term, the complainants' pending applications dated 15/10/2006 have not yet been honoured. Under the said circumstance there is a fear that the opposite parties are not keen in settling the claim of the complainants. Thus the complainants have been constrained to approach this Forum seeking redressal of their grievances.

2. Opposite parties 1 & 4 remain exparte.

3. Opposite parties 2 & 3 filed their 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 is paid by the CBT, EPF and not by the individual pensioners and medical reimbursement are 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 Co. 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 cashless 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 upto 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 submission and processing of claims for reimbursement are carried out by the claimants and 1^st opposite parties, the 2^nd & 3^rd opposite parties have no role in the process other than the case in which the insured has expired. In such cases the reimbursement allowed by the 1^st opposite party is released through the 3^rd opposite party. However, when some complaints regarding, the non-payment/delay in payment have been brought to the notice of the 3^rd 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.

4. PW1 has been examined on behalf of the complainants and Exts. P1 to P9 were marked. DW1 has been examined on behalf of opposite parties 2 & 3 and Exts. D1 & D2 were marked.

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 grievance pleaded in the complaint is that the complainants have not been provided with medical reimbursement inspite of having been enrolled in the policy and assigned valid PIN (Personal Identification Number). Opposite parties 2 & 3contend 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. The opposite parties 2 & 3 admit that during the period between 9/6/2003 and 8/9/2005, the medi-claim scheme under the 1^st opposite party was in operation and the medi-claim policy was kept alive by the 2^nd & 3^rd opposite parties.

6. The witness for the opposite party who has been examined as DW1 has deposed that ഈ case – ലെ complainants ന്‍െറ claim നാളിതുവരെ settle ചെയ്തിട്ടില്ല . 1^st opposite party – യുടെ ഭാഗത്ത് deficiency ഉണ്ടായി എന്നറിഞ്ഞുകൊണ്ടാണ് നിങ്ങള്‍ അവരെ disengage ചെയ്യുകയും 24/10/2006 മുതല്‍ CSMA Rules - ന് കീഴില്‍ engage ചെയ്യുകയും ചെയ്തത് (Q) അതെ (A). 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.

In the result, complaint is allowed. The complainants are entitled for refund of the claim amount with 9% interest from the date of claim till realisation. Hence the 1^st opposite party is directed to refund Rs.12,071.48/- with 9% interest from 15/10/2006 till realisation. Since interest has been ordered, there is no separate order as to compensation. The opposite parties shall also pay a cost of Rs.2,500/- to the complainants. Time for compliance 2 months.

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.108/2007

APPENDIX

I. Complainants' witness:

PW1 : P. Suseela

II. Complainants' documents:

P1 : Copy of the medi claim scheme

P2 : Copy of communication evincing the appointment of M/s. Genins India Ltd as TPA

P3 : Copy of medical bills of 2^nd complainant.

P4 : Copy of claim form dated 15/10/06 of the expenses incurred at Jubilee Hospital.

P5 : Copy of claim form dated 15/10/2006 of the expenses incurred at Sree Chitra Institute of Medical Sciences.

P6 : Copy of the letter sent by the 1^st complainant dated 22/12/06.

P7 : Copy of the letter dated 27/1/2007.

P8 : Communication issued by the Regional Provident Fund Commissioner (HRM) dated 23/2/2006.

P9 : 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 dt. 3/8/04 issued by the Central PF Commissioner.

D2 : Copy of detailed instructions issued by the Central PF Commissioner vide dated 18/10/06

PRESIDENT