PRESENT SRI P.V. NAGESWARA RAO, M.A., LL.M., PRESIDENT

      Friday, 24^th September 2010

 

 

 

 

          This complaint coming on this day for final hearing on 24-9-2010 in the presence of Sri G. Trivikram Singh, Advocate for complainant and Sri D. Lakshminarayana, Advocate for R1 and Sri D.V.S. Prasad, Advocate for R2 to R4 and upon perusing the material papers on record, the Forum made the following:-

 

1.                Complaint filed under section 12 of the Consumer Protection Act 1986.

 

2.                The brief facts of the complaint are as follows:- The complainant was an agent with code No. 2443659 of R1 and also Member of Zonal Manager in the R1 Corporation. He was a member of Divisional Manager also. R2 was a branch office of R3 dealing with medical insurance claims having interlinked with R2, R3 and R4. The R1 took a Group Medical Insurance policy in favour of its members (Agents) from them. The R1 was the policy holder and primary beneficiary was the complainant. From 2006 onwards the complainant was covered with medical insurance policy being taken by R1 from R4. The policy could be renewed from time to time for each year. The medical insurance policy bearing No. 121440/34/08/87/00000642 was taken in the name of R1 for the benefits of its members. As per terms of the policy in case of medical expenses incurred by the members, the R2 to R4 were liable to indemnify the same by refunding medical expenses.   Similarly the complainant was covered with the medical insurance policy. The premium was deducted by R1 from the commission amount payable to the complainant. 

 

3.                The complainant was operated at Swarnamrutha Hospital, Tirupati  on 6-9-2008 for Sinusitis problem and spent Rs. 35,568/- towards hospital bills. The amount had to be remitted by R2 to R4 as per policy. The complainant made a claim towards hospitalization charges through R1, who inturn forwarded the claim to R2 to R4. In the first instance R2 and R3 refused to accept the claim on some technical grounds. After getting clarification from R1 they received the claim of the complainant. The complainant submitted all original bills and required documents for settlement of the claim. But the complainant received many letters from R2 & R3 calling for so many requirements. The complainant sent replies properly and stated that all the original documents have been submitted for settlement of the claim. However, the R2 and R3 used to send letters to submit the documents which were already submitted by the complainant. Atlast the complainant on             2-12-2009 got issued a legal notice to the customer’s service department of R3 to settle the claim and reminded that he submitted all the documents also. The R2 and R3 were silent even after receipt of the notice either to settle or to repudiate the claim. The complainant approached R1 and informed his grievances for non settlement of his medical claim by R2 and R3. The R1 expressed his inability in solving the problem. The R1 gave evasive replies. 

 

4.                As per medical insurance policy the complainant was entitled for reimbursement to a tune of Rs. 60,000/-. The R2 to R4 were liable to pay                    Rs. 35,568/- towards hospitalization charges. The R2 to R4 were silent for 1 ½ years but again calling the original documents though they were submitted already. The fact of submitting the original documents was informed to R2 to R4 and the R1 failed to do needful to the complainant. It was the duty of R1 to take initiation in settlement of the claim by R2 to R4. The R1 was added as formal party in the complaint. But it was a necessary party for proper adjudication.   Thus, the respondents were deficient in service and hence, the complaint was filed for Rs. 35,568/- towards hospitalization charges together with interest @ 24% p.a. from the date of claim till the date of realization and Rs. 50,000/- towards mental agony and Rs. 2,000/- towards costs from R2 to R4. 

 

5.                The R1 filed a counter stating that the complainant himself had stated that R1 was a formal party and no relief was claimed.   Hence, the complaint may be dismissed against R1. It was not correct that the respondent did not take any interest in settlement of the claim, except forwarding the application received from the member. The corporation had nothing to do with the settlement of the claim. The respondent corporation received an application from the petitioner claiming medi claim expenses on 24-10-2008 and forwarded to R2. The petitioner’s club membership and his coverage under the policy were confirmed while sending the application itself.  The corporation followed up the matter on several occasions by phone and through letters dt. 16-2-2009 and 9-9-2009 and tried to settle the petitioner’s claim by reporting that the claim was genuine.  Once the application was forwarded the TPA would be directly dealing with the claim regarding further requirements if any and even sending the cheques to the claimant directly. Settlement of the claim or repudiation of the claim was concerned to R2 and R3.   The respondent was not concerned with the same.  Therefore, there was no deficiency of service and hence, the complaint may be dismissed with costs. 

 

6.                The R4 filed a counter adopted by R2 and R3 with a memo. The respondent admitted the medical insurance policy through R1 and as soon as the policy was issued, it was maintained and administered by 3^rd party administrator i.e. R2 and R3 including the settlement of any claim and the respondent had nothing to do with the claim.  It was known to the complainant and therefore, the correspondence was with R3 only and was not with R4.   It was not correct that the claim was forwarded to R4 through R1. It was not correct that at the first instance R2 and R3 refused to accept the claim on technical grounds and later accepted after getting clarification from R1. The complainant had not filed the refusal of the claim by R2 and R3 and such correspondence took place in between R2 and R3 with R1.  The medical records and entire case sheet was not submitted to R3 for settlement of the claim.   The R3 was corresponding with the complainant through letters. The complainant filed some letters but failed to file some more letters. The complainant failed to comply the requirements to R3 though it was specifically mentioned in the letters. Though the complainant failed to submit all the required documents yet the R3 processed the claim and settled the claim for Rs. 34,372/- by way of cheque bearing No. 358316, dt. 27-5-2010 drawn on Axis Bank Ltd., and sent to the complainant. Even after receipt of the cheque the complainant was processing the case against the principles of justice.   There was no deficiency of service because the R3 discharged itself in a perfect manner. Therefore, the complaint may be dismissed with costs. 

 

7.                On the basis of the above pleadings the following points are settled for determination. 

i.                   Whether there is any negligence and deficiency of service on the part of the Respondents?

ii.                 Whether the complainant is entitled to the relief as prayed for?

iii.              To what relief?

 

8.                On behalf of the complainant Ex. A1 to A9 were marked. No documents were filed for the Respondents.      

 

9.                Point No. 1& 2.   It was not a dispute that the complainant was an agent of R1 and was a member of the Zonal Manager in the corporation of R1 and R1 took a medical insurance policy from R4 administered by R2 and R3.  The complainant became a beneficiary under the policy obtained by R1. The R2 to R4  also admitted the medical insurance policy issued in favour of R1.   As per terms of the policy in case of medical expenses incurred by the members (agents) the R2 to R4 were liable to indemnify the same and refunded the medical expenses. The premium amount had to be deducted by R1 from the commission amount payable by R1 to the complainant.  

 

10.              On 6-9-2008 the complainant was operated for Sinusitis problem at Swarnamrutha Hospital, Tirupati and spent Rs. 35,568/- towards hospital charges. The complainant filed Ex. A1 a Photostat copy of discharge summary issued by Swarnamrutha Hospital, Tirupati together with Photostat copies of medical bills.  It was an admitted fact by R1 that the R1 received a claim application from the complainant on 24-10-2008 and forwarded to the R2 and reminded the matter by letters to settle the claim of the complainant. Therefore, the claim had to be settled by R2 and R3. R4 had only issued policy. In the counter of R4 also it was stated that the claim had to be settled by R2 and R3 and R4 had nothing to do with the claim.   After submitting the claim application the complainant wrote letters to R2 and R3, who addressed letters Ex. A2, dt.              17-4-2009, Ex. A3, dt. 5-5-2009, Ex. A4, dt. 30-7-2009, Ex. A5, dt. 23-12-2009 requesting to furnish hospital bills with breakup. Ex. A2 to Ex. A5 were computer generating documents. On 12-6-2009 and on 22-7-2009 under Ex. A6 and Ex. A7  respectively, the complainant stated that he submitted all the original bills with break up for settlement of the claim. Ex. A6 and Ex. A7 were Photostat copies.  The R1 also addressed a letter Ex. A8 to R2 on 16-2-2009 that the claim of the complainant was genuine. Ex. A8 was Photostat copy. The complainant filed Photostat copy of the medical insurance claim for club member agents under Ex. A9. Since the claim was genuine, the R2 issued a cheque in favour of the complainant for Rs. 34,372/-, dt. 27-5-2010 received by the complainant on        5-6-2010. A memo was filed to that effect by the complainant on 1-7-2010.  The complaint was filed on 22-5-2010. The date of posting for appearance was          01-7-2010. On 01-7-2010 the complainant filed a memo that the cheque for the said amount was received on 5-6-2010 under protest and sought for interest on the claim amount. The R1 has stated in the counter itself that the claim application with all the documents and bills with break up were submitted on          24-10-2008. The complainant made correspondence with R2 and R3 and R2 and R3 addressed letters under Ex. A2 to A5 without settling the claim. The R1 also addressed a letter to R2 under Ex. A8 before filing of the complaint.  However, the R2 and R3 were silent. The claim of the complainant was Rs. 35,568/-. The R2 sent Rs. 34,372/- by way of cheque. Therefore, the R2 and R3 had to pay balance amount of Rs. 1,196/- to the complainant. Since the R2 and R3 failed to settle the claim since a long time even after submitting all the documents,  the complainant is entitled to interest @ 9% p.a. from the date of claim till the date of realization on Rs. 35,568/-. The R2 & R3 are liable to pay Rs. 2,000/- towards mental agony and Rs. 1,000/- towards costs to the complainant. Hence, the points are answered accordingly. 

 

11.              Point No. 3. In the result, the complainant is allowed, directing the R2 & R3 to pay balance amount of Rs. 1,196/- (Rupees one thousand one hundred and ninety six only) to the complainant. The R2 & R3 failed to settle the claim since a long time even after submitting all the documents, the complainant is entitled to interest @ 9% p.a. from the date of claim till the date of realization on Rs. 35,568/-. The R2 & R3 are liable to pay Rs. 2,000/- (Rupees two thousand only) towards mental agony and Rs. 1,000/- (Rupees one thousand only) towards costs, payable within 45 days from the date of receipt of this order. The case against R1 and R4 is dismissed without costs. 

 Dictated to the Stenographer, transcribed by him, corrected and pronounced by us in the open forum, this the 24^th September 2010

 

 

Witnesses examined.

For Complainant    NIL                                                  For Respondent :     NIL

Exhibits marked for Complainant : -  

 

 

Exhibits marked for Respondents : -          ---- NIL -----

 

 

 

 

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