IN THE CONSUMER DISPUTES REDRESSAL FORUM, KOLLAM

            DATED THIS THE 1^st    DAY OF June 2018

Present: -    Sri. E.M.Muhammed Ibrahim, B.A, LLM. President

        Sri. M.Praveen Kumar,Bsc, LLB ,Member

       CC.No.104/2015

1.P.J.Kochu Mathew                                 :                  Complainants

Breeze Kampancodu

Vayakkal P.O

Kollam District

Kerala – 691532

2.Baby Mathew

W/o P.J. Kochu Mathew

Breeze Kampancodu

Vayakkal P.O

Kollam District

Kerala – 691532

[By Adv.Bijeesh.S.Pillai, Kottarakkara]

V/S

          1.       The Branch Manager            :        Opposite parties

                   Indian Overseas Bank

                   Thevannoor Branch

        Kollam District

       [By Adv.Kallada.M.Balachandran & K.Biju, Kollam]

          2.       Indian Overseas Bank

                   A body corporate duly constituted under the Banking Companies

                   (Acquisition and transfer of Undertaking)Act, 1970

                   having its Central Office at 762, Anna Salai Chennai – 600002

          3.       E-Meditech (TPA) Services Limited

                   2G Continental Plaza, 705, Mount Road

                   Chennai- 600006

          4.       M/s Universal Sompo General Insurance Company Ltd

Registered Office Unit.401, 4^th Floor, Sangam Complex, 127, Andheri , Kurla Road, Andheri (East), Mumbai - 400059         

                   [By Adv. Saji Isaac.K.J, Kochi]

                                                         (2)

ORDER

SRI. M. PRAVEEN KUMAR, MEMBER

          This is a case based on consumer complaint filed by the complainant against 4 opposite parties Under Section 12 of the Consumer Protection Act  1986, seeking to direct the opposite parties to pay an amount of Rs.1,50,000/- being the assured policy amount and with interest  @12% per annum from 28/01/2014 ie the date of surgery and also seeking an amount of Rs.1,00,000/- with interest @12% per annum to the 2^nd complainant as compensation for mental agony, financial loss and physical harassment caused to the complainants due to the illegal acts of the opposite parties  along with costs of the proceedings.

The averments in the complaint in short are as follows, the complainant is a retired bank employee and the 2^nd complainant is his wife . At the time of retirement the 1^st complainant was designated as Assistant Manager at Njetoor, Kulanada Branch of Indian Overseas Bank. The 1^st opposite party is the Branch Managr of 2^nd opposite party. The 2^nd opposite party introduced a retiree benefit scheme for their retired employees through his branch office at Thevannoor, Kottarakkara, where from the 1^st complainant is receiving his pension also. Opposite party 2 decided to introduce a new group health insurance scheme with the tie up of opposite party No.4 ie retired employees medical assistance scheme (herein after mentioned as REMAS) as per which, the limit of coverage per family was to be Rs.1,50,000/- covering self and spouse, implemented w.e.f.01/07/2012. 

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Complainant retired from service on 31/01/2001. As per the scheme (retired employees medicals assistance scheme ) members were to be benefited out of cashless facility for their hospitalization claims subject to 20% of co-payment clause and as per circular  dated 26/07/2012 add o benefits viz  coverage of pre- existing diseases, waiver of exclusion of waiting period of 30 days, waiver of exclusion of first year,  policy coverage age ban of 50-90 years and coverage of health due to the accident  of retiree (not spouse) for Rs.2,00,000/- were provided. After reading the circular dated 26/07/2012 that the complainant deposited the requisite fees to become a member of the group welfare society of opposite party no.2. Complainant has subscribed the said scheme by paying one time subscription fees of Rs.12,850/- as per his retirement and issued with the policy bearing No.2816/52396325/00/000. Opposite party No.4issued an identity card to the 1^st complainant and his spouse valid from 01/10/2012.  The 2^nd complainant aged 60 years old was admitted in Kerala Institute of Medical Science (KIMS), Thiruvananthapuram on 27/01/2014 for treatment of knee problem and she was advised knee replacement surgery. Complainant deposited  Rs.1,30,000/- on 27/01/2014 as advance the date of surgery was on 28/01/2014, and after the knee replacement surgery , 2^nd complainant was discharged from the hospital on 03/02/2014 the discharge summary is produced herewith, the total package for treatment of Rs.2,24,611/- out of which Rs.74,611/- was paid by the complainants , the balance amount of Rs.1,50,000/- could have been paid by opposite party No.3

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as per the Retired Employees Medical Assistance scheme . 1^st complainant enquired about the claim procedure and sent the total estimated cost of treatment to the E-meditek (TPA) services limited, through E-mail but the medical claim of the 2^nd complainant was rejected by opposite party 3 vide letter dated 20/12/2012, on the ground that the waiting period for the ailments of joint replacement due to degenerative conditions and the age related osteoarthritis and osteoporosis was 3 years under the policy. The repudiation of the policy was wrong an unjustified because as per the circular , there was no such  condition in the policy. Opposite parties mislead the complainant and rejected the claims on flimsy grounds. At that time the financial conditions of the complainants were verse and they suffered a lot for arranging the money. The 1^st complainant arranged the money lenders by paying huge interest . The 1^st complainant sent duplicated copy of claim form and covering letter along with duplicate bills and all concerned papers to the chief officer, PAD (Welfare Section)Pension Cell, Central office, Indian Overseas Bank, Annasalai, Chennai on 21/01/2014 copy of the same is produced herewith. Complainant sent several emails to 2^nd, 3^rd and 4^th opposite parties regarding the reimbursement of his claims.   The rejection of the complainant’s genuine claim by the opposite parties highly affected the financial status of complainants and put them into a sudden financial crisis. The complainants are senior citizen ailing from several diseases. The mental agony suffered by the complainants cannot be quantified. Even though the complainant has furnished the detailed along with

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original bills to the opposite parties and the communications made with them till date, the opposite parties are not ready to heed with the lawful and genuine demands of the complainants. The complainant had issued a lawyers notice to the opposite parties for disbursing the insurance amount to the complainants. Even though the opposite parties 2 and 4 received the notice on 19/01/2015 and 20/01/2015 respectively, they have not disbursed the amount nor sent any reply. Hence the complainants approached the forum for relief.

          The 1^st and 2^nd opposite party filed written version raising the following contentions.  It is true that the proposal regarding the group insurance scheme of the 4^th opposite party was introduced to the first complainant by the first opposite party. The application form with instructions and circulars of 4^th opposite party were  supplied to complainants by first and second opposite parties .  The 2^nd opposite party is only an agent of the 4^th opposite party in enrolling subscribers to the above group health insurance scheme. The 1^st and 2^nd opposite parties have no tie up with 4^th opposite party. The group health insurance scheme named Retired Employees Medical Assistance  Scheme (REMAS) was introduced by the 2^nd opposite party  for rendering medical help to the their retired employees. The 4^th opposite party came forward to render health insurance benefits to the members of “REMAS” .  On the basis of the circular No.30 of 2012-2013 was issued by the second opposite party. To enroll as subscriber of the above group insurance scheme was the option of the retired employees. The 1^st complainant on going

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through the terms and conditions stipulated in the circular, voluntarily opted to subscribe to the scheme. The contractual liability regarding the benefits of insurance is between complainants and the Insurance company (opposite party 3 and 4). The 3^rd and 4^th opposite parties are liable to settle the legitimate claims of the complainants.   Complainant have no right to proceed against first and second opposite parties in the absence of an existing contractual liability with the first and second opposite parties. The rejection of the claim of complainants by the 3^rd and 4^th opposite parties was brought to the notice of first and second opposite parties after one month .  The second opposite party immediately contacted the 4^th opposite party and tried their best to settle  the matter in favour of complainants . For that purpose the original medical bills and other connected documents were collected from complainants and forward the same to the 4^th opposite party.  But  the  4^th opposite party was not prepared to settle the claim on the ground that there is violation of the policy conditions. That fact was informed to the complainants . There is no deficiency  in service on the part of  the 1^st and 2^nd opposite parties .  The allegation that complainant sent a letter to the Executive Director of Indian Overseas Bank on 05/11/2014 and it was not replied is not correct . The lawyer’s notice issued were promptly replied on stating the true facts. The complainant is not entitled to realize any amount from the 1^st and 2^nd opposite parties by way of compensation, interest and costs.

          3^rd opposite party did not filed any written version.

          (7)

The 4^th opposite party filed written version raising the following contention.

          It is true that 4^th opposite party had issued a group health insurance policy to Indian Overseas Bank for the period  from 01/07/2012 to 30/06/2013. The optional extension opted by Indian Overseas Bank for the policy was coverage against pre-existing diseases, waiver of 30 days waiting period, waiver of first year exclusion.  The policy was issued to Indian Overseas Bank covering theses optional extension.  According to the endorsement forming part of policy No.2816/52396325/00/000, the waiting period for the ailments of joint replacement due to degenerative conditions and age related osteoarthritis and osteoporosis is 3 years under the policy, irrespective of pre-existing disease covered. As admitted by the complainant , the 2^nd complainant had knee replacement surgery . The 4^th opposite party had not issued any circular to the complainant and is not liable to the complainant for any circulars issued by the 1^st and 2^nd opposite parties and 4 the opposite party is also not aware of the circular produced as document .No.7 and 8 and hence those documents are denied by this opposite party.  Opposite party 4 has issued the policy to Indian Overseas Bank and had also supplied the terms and conditions of the policy. It was the duty of the 1^st and 2^nd opposite parties to disclose all the material facts relating to the coverage to the members of the scheme who were their retired employees. 4^th opposite party had rejected the claims of the complainant based on the terms and conditions of the policy . 4^th opposite party had not received any communication from the 1^st complainant

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regarding the repudiation of claim. Opposite party 4 is not liable to give any relief, compensation , costs to the complainants. There was no deficiency in service and unfair trade practice on the part of 4^th opposite party.

In view of the pleadings the following points raised  for consideration.

1.whether there was any deficiency in service a=or any unfair trade practice on the part of opposite parties?

2. Whether the complainant is entitled to get the reliefs sought for?

3.Reliefs and costs?

Complainant was examined as PW1 and got marled Exts.P1 to P17 documents. Opposite party has not adduced any oral evidence but got marked Ext.D1 though notice was received opposite party No.3 has neither appeared nor filed any written version so far. Hence opposite party No.3 set exparte on 28/09/2015.

Counsel appearing for complainant and opposite parties 1, 2 and 4 has advanced arguments and filed notes of arguments also.

Points No.1 and 2:-

          For avoiding repetition of discussion of materials these two points are considered together. Admitted case of the parties is that complainant is a retired bank employee and the 2^nd complainant is his spouse and his retirement date is on 31/01/2001. 2^nd opposite party introduced a retirement benefit scheme for their retired employees   through   his branch office  at Thevannoor, Kottarakkara.  The

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welfare section of  opposite party No.2 decided to introduced a new group health insurance scheme with the tie up of opposite party No.4. Complainant deposited the requisite fees to become a member of the group welfare society of opposite party No.2. Complainant had subscribed the scheme by paying one time subscription fees of  Rs.12,850/- as per his entitlement and issued with the policy bearing No.2816/52396325/00/000.Opposite party No.4 issued an identity card to the 1^st complainant and his spouse valid from 01/10/2012. The limit of coverage per family was to be Rs.1,50,000/- covering self and spouse with effect from  01/07/2012 which offers members were to be benefited out of cashless facility for their hospitalization claim subject to 20% of co-payment clause . 2^nd complainant was admitted in KIMS hospital on 27/01/2014 and knee replacement surgery was conducted and complainant paid Rs.2,24,611/- for treatment.

          Here the crucial  question arise for consideration is :-

          Whether the complainant eligible to get Rs.1,50,000/- as treatment expenses from opposite party 4.

          Learned counsel for the complainant submitted that complainant and her spouse has taken policy bearing No. 2816/52396325/00/000 from opposite party No.4 which covers cashless facility for their hospitalization claim subject to 20 % of co payment clause and as per the circular dated 26/2/2017 add on benefit wise coverage of pre-existing diseases , waiver of exclusion of waiting period of 30 days, waiver of exclusion  of 1^st year, policy coverage age ban of 50-90 years and

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coverage of death due to the accident of retiree were Rs.2 lakhs will provided. Ext.P.9 and 10 photocopy of  identity cards No.10010120014764A & 10010120014764B vide policy number  2816/52396325/00/000 issued to the complainant would prove that complainant have a valid policy from 01/10/2012 and Ext.P7 copy of circular No.7F/CIRNO.43/2014-15 dated 15/7/2014 would prove that as per the scheme members were to be benefited out of cashless facility for their hospitalization claims subject to 20% of co-payment clause, and as per circular dated 26/7/2012 add on benefits viz, coverage of pre-existing diseases, waiver of exclusion of waiting period of 30 days, waiver of exclusion of first year, policy coverage age ban of 50-90 years and coverage of death due to the accident of retiree (not spouse) for  Rs.2 lakhs were provided. Learned counsel for the complainant further submitted that this spouse of the 1^st complainant admitted at KIMS hospital , Thiruvananthapuram on 27/01/2014 and conducted knee replacement surgery and paid Rs. 2,24,611/- . Ext.P15 series (28 Nos) medical bills would prove that 1^st complainant deposited Rs.1,30,000/- on 27/01/2014 as advance , the date of surgery was fixed on 28/01/2014 and after the knee replacement surgery, 2^nd complainant was discharged from the hospital on 03/02/2014 . Complainant paid Rs. 2,24,611/-  for his spouse treatment at KIMS Hospital . Counsel for the complainant argued that the total package for treatment of Rs. 2,24,611/-  out of which Rs.74,611/- was paid  by the complainants, the balance amount of Rs.1,50,000/- would have been paid by opposite party No.3 as

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per the REMS scheme  and also submitted that the rejection of complainants genuine claim by the opposite parties highly affected by the financial position of complainants and put by them a sudden financial crises. Moreover 1^st complainant is a senior citizen and he is having 67 years old ailing from several diseases.

          The insurance company has a  tie up with the Indian Overseas Bank for the limited purpose of canvassing their retired employees to subscribe the medi claim policy of the 4^th opposite party. 2^nd opposite party bank is only an agent of the 4^th opposite party in enrolling subscribers to the Group Health Insurance Scheme, floated by 4^th opposite party for the benefits of the retired employees of the bank.

The counsel for the 4^th opposite party argued that 4^th opposite party had issued a group health insurance policy to Indian overseas bank for the period from 01/07/2012 to 30/06/2013. The optional extension opted by Indian Overseas Bank for the policy was coverage against pre- existing diseases, waiver of 30 days waiting period, waiver of first year exclusions. The policy was issued to Indian Overseas Bank covering these optional extensions and as per policy number 2816/52396325/00/000, the waiting period for the ailments of joint replacement due to degenerative conditions and age related osteoarthritis and osteoporosis is 3 years under the policy, irrespective of pre-existing disease covered. As admitted by the complainant, the 2^nd complainant has knee replacement surgery.  Hence it is contented that the 4^th opposite party is not liable  to compensate the complaint. It is further    argued that the   4^th opposite party is   also not aware of the circular dated

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26/07/2012 and 15/07/2014 (Ext.P7 and P.8) and 4^th opposite party is have no liability for whatever is stated in the Ext.P7 and P8 circular documents.

But counsel for the complainant vehemently argued that as per the scheme, members were to be benefited out of cashless facility, for their hospitalization claims subject to 20 % of co-payment clause, and as per circular dated 26/07/2012 add on benefits viz. Coverage of pre-existing diseases, waiver of exclusion of waiting period of  30 days, waiver of exclusion of first year, policy coverage age ban of 50-90 years and coverage of death due to the accident of retiree (not spouse)  for Rs.2 lakhs were provided. The copy of circular No.7 FCIRCULARNo.30/2012-13 dated 26/7/12 is produced and marked as Ext.P7. Copy of circular No.7F/CIRCULAR No.43/2014-15 dated 15/07/2014 is produced and marked as Ext.A8.

Ext.P9 and P.10 cards would prove that complainant and his spouse (2^nd complainant ) having valid policy which starts  from 01/10/2012 group name Indian Overseas Bank , policy number 2816/52396325/00/000 and stated that cashless facility can be availed.

Opposite parties have not produced any materials to disprove the terms and conditions of Ext.P7 and P.8 circulars. The above said policy carries benefit, conditions and coverage .The benefits payable only as per the conditions of policy.

 As per circular No.30 of 2012-13 dated 26/07/2012 the salient features of the group health insurance scheme are as under.

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1. Treatment in the hospitals/nursing homes in India are covered .
2. Limit per family shall be Rs.1,50,000/- covering self and spouse on family floater basis.
3. Members will be benefited out of cash less facility for their hospitalization claim subject to 20% of co-payment clause.

Add on benefits:-

• Pre-existing  diseases will be covered
• Waiver of exclusion of waiting period of 30 days
• Waiver of exclusion of first year
• Policy covers the age bond of 30-90 years
• Coverage of death due to accident of retire (not spouse) for Rs.2 lakhs.

 As per circular No.43 of 2014-15 dated 15/07/2014 the salient features of the group health insurance scheme are as under.

• The policy is issued on family floater basis.
• The sum insured per family is Rs.1,50,000/-.
• Policy cover is available to retired employee and spouse only.
• Maximum age limit for coverage is up to 98 years.
• The policy covers inpatient hospitalization expenses incurred in India only and the period of hospitalization should not be less than 24 hours.

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• Domiciliary treatment expenses are not covered under the policy.
• Room, boarding and nursing expenses as provided in the hospital/nursing home subject to following limits.

1. Sub limit per day for normal room expenses : 1% of sum insured.
2. Sub limit per day for intensive care/therapeutic unit expenses 2% of sum insured.

• 30 days waiting period  waived off under the policy.
• First year exclusions waived off under the policy
• Pre-existing  diseases are covered under the policy. The waiting period for the ailments of joint replacement due to degenerative conditions and age related osteoarthritis and osteoporosis is 3 years under the policy, irrespective of  pre-existing diseases covered.

Perusal of the medical records issued from the KIMS Hospital , Triruvananthapuram would show that 2^nd complainant was under treatment of knee replacement and charged Rs.2,24,611/- which would come under the policy coverage . As per the terms and conditions of circulars marked as Ext.P7 and Ext.P8, opposite party No.4 is liable to give an amount of Rs.1,50,000/-.

          On examination of medical records , bill Ext.P7,P.8, P10 documents we are on the view that opposite parties wrongly repudiated the claim of the complainant and there is gross negligence , deficiency in service and unfair trade practice on the

part of opposite party No.4 and hence liable to pay compensation and reliefs.

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Points answered accordingly.

Points No.3:-

In the result complaint stands allowed in part. Opposite party No.4 is directed to pay an amount of Rs.1,50,000/- being the medical expenses   complainant with 9% interest per annum from date of repudiation ie 22.1.14 and opposite party No.4 is also directed to pay an amount of Rs.25000/- being compensation for the mental agony and hardships to the complainant. Opposite party No.4 is further directed to pay Rs.5000/- as costs of  the proceedings within 45 days from the date of  receipt of this order, failing complainants No.1 and 2  can realize an amount of Rs.1,75,000/- with interest @12% from the date of repudiation along with cost of the proceedings till realization  from the opposite party No.4 and their assets.

Dictated to the  Confidential Assistant Smt.Vijimole.G transcribed and typed by her corrected by me and pronounced in the  Open Forum on this the  1^st   day of June 2018.

                                                                                                E.M .MUHAMMED IBRAHIM:Sd/-

                                                                                                M.PRAVEENKUMAR: Sd/-

                                                                                                Forwarded/by Order

                                                                                                Senior Superintendent

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INDEX

Witnesses examined for the complainant

PW1.:- P.J.Kochu.Mathew

Documents marked for the complainant

Ext.P.1 :-E-mail dated 22/01/2014

Ext.P.2:- Claim request dated 21/02/2014

Ext.P.3:- E-mail dated 24/4/2014

Ext.P.4:- E-mail dated 19/05/2014

Ext.P.5:- Covering letter of original medical bill and claim dated 25/6/14

Ext.P.6:- Letter dated 05/11/2014

Ext.P.7:- Copy of circular No.7F/ Circular No.30/2012-13  dated 26/7/12

Ext.P.8:- Copy of circular No.7F/ Circular No.43/2014-15  dated 15/7/2014

Ext.P.9:-  Complainant’s  No.1   Insurance card  copy

Ext.P.10:- Complainants No.2  Insurance card  copy

Ext.P.11:-  Application for membership 

Ext.P.12:- Notice claiming insurance (REMAS) benefits dated 13/01/2015

Ext.P.13:- Postal receipts (3 Nos)

Ext.P.14:- Acknowledgment card

Ext.P.15:- Kerala Institute of medical science  bills copy

Ext.P.16:- Postal receipts (2 Nos)

 Ext.P.17:- Email dated 23/07/2014

                                                                                E.M.Muhammed Ibrahim:Sd/-

                                                                               M.Praveen Kumar:-Sd/-

                                                                              Forwarded/by Order

                                                                              Senior Superintendent