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: 257/2006 Filed on 23/09/2006

Dated: 31..03..2010

Complainants:

1. Consumer Protection Council of Kerala, Reg.No.T.198/1985, Represented by its 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 allegations in the complaint are the following: 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. M/s. Genins India Limited, Noida is the Administrative agency given charge by the 1^st opposite party with regard to settlement of medi-claims, and they have been given charge of the same since 3^rd August 2004. The 2nd opposite party is still 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. Repeated requests and reminders on part of the members directly, and the 2^nd complainant association collectively, to the opposite parties have evoked no 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 remains 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 complainant and Exts. P1 to P4 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 pensioners whose names have been mentioned in the complaint, 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 1^st opposite party has not appeared before the Forum. The allegations levelled against the 1^st opposite party and 4^th opposite party stand uncontroverted.

7. The opposite parties 2 & 3 though argued that the complaint is bad for non-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 dealings. 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. 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: Smt. Omana K. Nair (PIN 03563) Rs. 7,658.-, Shri. P.R.K Nair (PIN 03562) Rs. 2,450/-, Smt. P. Saraswathy (PIN 00070) Rs. 33,450/-, Shri. K.K. Raman Nair (PIN 01802) Rs. 4,200/-, Shri. K.K. Raman Nair (PIN 01803) Rs. 1,04,977/- and Smt.Sugantha Kumari (PIN 02015003 – 010004851 (old No.00178) Rs. 7,332/-. 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.

In the result, complaint is allowed. The 1^st opposite party shall settle the insurance claims of the members as mentioned Supra except that of Smt. Omana Amma who is no more. Since interest has been ordered, there is no separate order as to compensation. The opposite parties shall also pay 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.

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C.C.No.257/2006

APPENDIX

I. Complainants' witness:

PW1 : C.V. Gopinathan Nair

II. Complainants' documents:

P1 : Copy of Mediclaim Scheme for the pensioners of Employees Provident Fund Organisation (EPFO) & their spouses.

P2 : Copy of communication dated 1/10/04 appointing Gennis India Ltd., Noida as the third party administrator of the 1^st opp. Party.

P3 : Copy of letters send by 1^st complainant to the 1^st opp. Party (7 in number)

P4 : Copy of letter issued by the Regional Provident Fund Commissioner (HRM) bearing No.HRM- V/12(7) 2005-06/OIC/renewal dated 23/2/2006.

III. Opposite parties' witness:

DW1 : K. Parameswaran

IV. Opposite parties' documents:

D1 : Copy of letter dated 3/8/04 issued by the Central PF Commissioner.

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

PRESIDENT

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