By Sri. Chandran Alachery, Member:

The complaint is filed under section 12 of the Consumer Protection Act for an order directing the Opposite parties to pay Rs.48,000/- with 18% interest per annum towards the expenses incurred by the Complainant for the treatment and to pay Rs.20,000/- as compensation and cost of the proceedings.

2. The Complainant's case in brief as follows:- The Complainant is a milk producer and a member of 3^rd Opposite Party Society. The Opposite Parties jointly launched an insurance scheme for meeting the treatment expense of milk producers. The Complainant joined as a member of the scheme with membership No.1201160162. Prescribed amount for joining in the scheme was also given to the Supplementary Opposite Party No.5. From 01.01.2010 to 11.01.2010 the Complainant was admitted to treat for Hemoptysis and fever at Fathima Matha Hospital Kalpetta and thereafter he was referred to MIMS Hospital Calicut and was admitted on 11.01.2010 and discharged on 18.01.2010. The Complainant had spent Rs.48,000/- towards the treatment. Thereafter the Complainant submitted claim form with all documents necessary for settling the claim to 3^rd Opposite Party. But the Opposite Parties repudiated the claim. The Opposite Parties denied the claim to the Complainant without any reasonable or valid grounds. Hence Complainant says that there is deficiency of service from the part of Opposite Parties. Hence this complaint.

3. On receipt of complaint, notices were served to Opposite Parties and Opposite Parties appeared before the Forum and filed version. 1^st Opposite party contended that the application of the Complainant related to insurance claim for his hospitalisation was received and forwarded by these Opposite parties to 4^th Opposite party for settling the claim. But the 4^th Opposite party rejected the claim stating that “Pneumonia is not covered” as per the policy conditions. The 2^ndOpposite Party contended that the Complainant had submitted the claim application with necessary certificate and bills to the Nodal Officer through Dairy Extension Officer, Kalpetta on 16.03.2010. The Nodal Officer after proper verification recommended the application for payment and the same was forwarded to Kerala Diary Farmers Welfare Fund on 06.04.2010. Hence it evident that no laxity was committed from the part of Nodal Officer. The 3^rd Opposite Party filed version and stated that the Complainant had remitted Rs.100/- to the 3^rd Opposite Party in order to join the scheme and 3^rd Opposite Party remitted this amount with 1^st Opposite Party. More over 3^rd Opposite Party pays Rs.20/- every month on behalf of the Complainant with 1^st Opposite Party. By using these amounts, 1^st Opposite Party pays the insurance premium with 4^th Opposite Party on behalf of Complainant. 3^rd Opposite Party already send all medical bills of Complainant to 2^nd Opposite Party. So there is no latches on the part of 3^rd Opposite Party. 5^th Opposite Party filed version and stated that the Complainant has not mentioned the policy member or date of payment of premium amount etc. in the complaint. No claim intimation and claim form and relevant documents were not furnished to this Opposite Party by the Complainant or by the 1^st to 3^rd Opposite Parties. Hence this Opposite Party is not able to admit insurance coverage of the Complainant. The Opposite Parties denies the allegation that the Complainant is covered by the insurance coverage. Since no contract exist between the Complainant and this Opposite Party no deficiency of service on the part of the 5^th Opposite Party. Opposite Party No.4 filed version and stated as stated by 5^th Opposite Party.

4. On verifying the complaint, proof affidavit and version of 1^st to 5^th Opposite parties, the Forum raised the following points for consideration.

1. Whether there is deficiency of service from the part of Opposite Parties?

2. What order as to cost and compensation?

5. Point No.1:- In addition to complaint, the Complainant filed proof affidavit and is examined as PW1. 3^rd Opposite Party is examined as OPW1 and Exts.B1 to B3 is marked. 1^st Opposite party produced documents and marked as Ext.B4 and Ext.B5. No oral evidence is adduced by 5^th Opposite Party. As per order in IA 122/12, the name of the Opposite Party is deleted from the complaint and supplementary 5^th Opposite Party is impleaded. Ext.B4 is the MOU for the implementation of Insurance Scheme. Ext.B5 is the Kerala Diary Farmers Welfare Fund Ksheera Karshaka Insurance List of Application 98. Exts.B1, B2 & B3 are receipts for payment of premium amount by 3^rd Opposite party in Kerala Diary Farmers Welfare Fund account. On verification, it is found that before deleting the name of 4^th Opposite Party, the 4^th Opposite party filed version and denies only the receipt of claim form with relevant documents to 4^th Opposite Party in order to process the claim. Hence 4^th Opposite Party states that due to the non receipt of claim form from the Complainant, 4^th Opposite Party could not admit the insurance coverage of the Complainant. 5^th Opposite party in its version stated that 5^th Opposite Party did not receive any claim application from the Complainant or from the any other Opposite Parties. More over 5^th Opposite party contented that pneumonia is not a contagious disease and not covered as per MOU. Here 4^th and 5^th Opposite Parties specifically stated that they did not receive claim form from the Complainant or no claim form is forwarded to them by any other Opposite Parties. But 1^st Opposite Party clearly stated that the application of Complainant related to insurance claim was forwarded to 4^th Opposite party by 1^st Opposite Party. Here 4^th and 5^th Opposite Parties did not adduce any evidence with respect to the receipt of claim form, the actual reason for the repudiation etc.. As per Ext.B5 document, it is evident that the Complainant is also a member in the insurance scheme. 4^th and 5^th Opposite party had cross examined the OPW1 to the effect that the Complainant is not a member in the scheme. But there is no cross examination regarding the illness of Complainant. The Complainant in his cross-examination by 4^th and 5^th Opposite Parties, stated that he do not know the disease for

which treatment was done. 4^th and 5^th Opposite parties or any other Opposite Parties did not produce any document to prove the disease mere contention in the version is not sufficient to prove the case of the Opposite Parties. On analysing the entire evidence, the Forum found that the complainant is member in the Insurance Scheme and he did not receive the claim amount for reason best known to the Opposite parties. The Complainant is entitled to get the reasonable claim amount from the Opposite Parties. So the Forum found that there is deficiency of service from the part of supplementary 5^th Opposite party in dealing the claim of Complainant. Point No.1 is found accordingly.

6. Point No.2:- Point No.1 is found in favour of Complainant, the Complainant is entitled to get the cost and compensation.

In the result, the complaint is partly allowed and the supplementary 5^th Opposite Party is directed to pay Rs.48,000/- (Rupees Forty Eight thousand) only to the Complainant and Rs.1,000/- (Rupees One thousand) only towards compensation and Rs.1,000/- (Rupees One thousand) only towards cost of the proceedings. The supplementary 5^th Opposite party is liable to pay the above amounts within 30 days from the receipt of this order failing which the Complainant is entitled to get 12% interest for the whole sum thereafter.

Dictated to the C.A transcribed by him and corrected by me and pronounced in the Open Forum on this the 27^th day of August 2014.

Date of filing:13.01.2012.

PRESIDENT: Sd/-

MEMBER : Sd/-

MEMBER : Sd/-

/True copy/

Sd/-

PRESIDENT, CDRF, WAYANAD.

A P P E N D I X

Witness for the Complainant:

PW1. Joseph. T.C Complainant.

Witness for the Opposite Parties:

OPW1. Moly Secretary, Thenery Milk Society.

Exhibits for the Complainant:

Nil.

Exhibit for the Opposite Parties:

B1. Copy of Receipt. dt:11.01.2010.

B2. Copy of Receipt. dt: 06.01.2010.

B3. Copy of Receipt. dt:31.12.2005.

B4. Copy of the MOU for the Implementation of Insurance Scheme.

B5. Copy of Kerala Diary Farmers Welfare Fund Ksheera Karshaka Insurance

List of Application 98.