The complaint is filed  to direct the opp.party  to pay claim amount and other reliefs.

The averments in the complaint can be briefly summarized as follows:

Complainant is an account holder keeping savings bank account with the 3rd opp.party, and on the instigation of the 3rd opp.party the complainant had entered into the Mediclaim Insurance Scheme of the Indian Bank Arogya Raksha Plan with the United India Insurance Company Ltd. the 1st  party on 11.1..2008, that the complainant has insured for a sum of Rs.3,00,000/- and the family members of the policy holder will also get the benefits under this scheme, that the 1st opp.party had issued a insurance policy certificate dated 31..1..2008 to the complainant with policy No.2007/4841000223/22, that before taking the insurance policy the 1st and 3rd opp.party convinced to the complainant that the above group Mediclaim policy covers reimbursement of hospitalization expenses for illness and diseases or injury sustained by the insured person and his dependents, that the 1st and 2nd opp.party assured to the complainant that in the event of any claim under this group Mediclaim policy the company will pay to the injured person without any delay through the 2nd opp.party, that complainant’s wife Mrs. Fazila Sherafudeen was admitted at Assisi Atonement Hospital, Kollam on 24..1..2008 and diagnosed as carcinoma in breast as per the biopsy report on 28..1..2008 and the complainant’s wife was referred to expert treatment and she was treated at Amrutha Hospital and Lakeshore Hospital, Ernakulam, that she was undergone a major surgery at Lakeshore Hospital and there after 6 course of Chemotherapy and 24 days of radiation therapy was done and the complainant had extended a huge amount for the treatment of his wife and the treatment is now also continued, that as per the Indian Bank, Arogya Raksha Plan the complainant had filed his 1st Mediclaim application of Rs.10266/- with all relevant documents to the first opp.party through the 2nd opp.party and the 1st opp.party approved the same through the 2nd opp.party by way of City Bank cheque No.634356 dated 2..4..2008 to the complainant, that as per the continuation of the treatment complainant has submitted four Mediclaim application to the 1st opp.party through the 2nd opp.party of claim, application dated 14..4..2008 of Rs.29915/- and dated 19..5..2008 of Rs.34923/- and dated 16.6.2008 of Rs.19026/- and dated 9..7..2008 of Rs.79843/- with all relevant documents and certificates, that but the opp.parties not settled the above said claim application without any valid reason, so far that the complainant enquired about the above claim applications to the 3rd opp.party but the 3rdopp.party not respond properly, that on 23..6..08. the complainant had send a letter to the 2nd opp.party [T.T.K. Health Care Services about the claim applications but they not respond properly, that complainant had send a registered advocate notice dt. 25..9..2008 to the opp.parties and demanded to settle the above  referred four mediclaims applications with in 15 days from the date of receipt of the notice, but the opp.parties not respond so far.  Hence filed this complaint for getting Mediclaim amount

Opp.parties filed version contenting that, the 1st opp.party had issued a certificate of insurance in favour of the complainant covering the risk of the complainant and his family members to a maximum sum insured of Rs.3,00,000/- for a period commencing from 11.1.2008 to 1..1..2009, that the complainant was an account holder with M/s. Indian Bank, Polayathodu Branch, Kollam the 2nd opp.party and the policy was issued by this opp.party for the account holders of the 3rd opp.party under a special scheme namely ‘Indian Bank Arogya Raksha –Plan B’, that the liability of the 1st opp.party under the above policy is subject to the terms, and conditions, exclusions and exceptions incorporated in the policy terms and conditions, that as per the policy terms, the policy holders or the beneficiaries covered under the policy are supposed to submit their respective claims with the 2nd opp.party for settlement of the claim in compliance with the norms and regulations governing the admissibility of the claim, that the complainant submitted four claims before this opp.party in relation with the treatment of his wife during four intermittent occasions, that the first claim is for Rs.26,695/- for her inpatient treatment from 2.2.2008 to 17..3..3008, the 2nd claim for Rs.8,228/- for her inpatient treatment from 23..4..2008 to 30..4..2008, third claim for Rs.79,843/- for her inpatient treatment from 2..6..2008 to 5..7.2008 and the fourth claim for Rs.19026/- for her inpatient treatment from 23..4..2008 to 30..4..2008, at various hospitals, that the complainant has not reported any claim with the 3rd opp.party for Rs.34,923/- dated 19..5..2008 as stated in the complaint and the 2nd opp.party is totally unaware of the aforesaid claim in the absence of any claim intimation from the complainant, that the 2nd opp.party has considered all the other four claims reported by the complainant with them and the 2nd opp.party had already settled the above claims by considering the extent of admissibility of the respective claims subject to the terms and conditions of the policy, that the complainant has never lodged a claim with the 2nd opp.party for Rs.34,923/- with the supporting documents, certificates and details before the 2nd opp.party till date that so the 2nd opp.party has never given an opportunity to consider the above claim advanced by the complainant in his complaint, that in view of the facts and circumstances submitted the complaint is liable to be dismissed in limine with heavy compensatory cost to this opp.party.  Hence the opp.parties prays to dismiss the complaint.

Points that would arise for consideration are:

1.     Whether there is deficiency in service on the part of the opp.parties?

2.     Reliefs and cost.

For the complainant PW.1 was examined and Exts. P1 to P12 marked.

No oral or documentary evidence for the opp.parties

POINTS:

There is no dispute that at the  disputed time of treatment of the complainant’s wife, the complainant had a valid Insurance Policy with the 1st opp.party.   The grievance of the complainant is that though he submitted claims with supporting documents, the opp.parties did not allow his claims dated 14..4..2008 of Rs.29,915/- and dated 19..5..2008 of Rs.34,923/- and dated 16..6..2008 of Rs.19026/- and dated 9..7..2008  Rs.79,843/-

1st opp.party contested the case before the Forum.  3rd opp.party filed version stated that they are only a facilitator by arranging with 1st opp.party to offer value added Mediclaim cover to the Bank customers on competitive basis and they have not committed any unfair trade practice or deficiency in service to the complainant with regard to the 2nd opp.party , after receiving notice from the Forum did not appear.  Hence 2nd opp.party is declared as exparte.

According to the complainant he had submitted four Mediclaim applications to the 1st opp.party through the 2nd opp.party of claim application dt. 14..4..2008 of Rs.29,915/- dated 19..5..2008 of Rs.34,923/- dated 16..6..2008 of Rs.19026/- and dated 9..7..2008 of Rs.79,843/- with all relevant documents, bills and certificates.  But the opp.parties not settled the above said claim application without any valid reason.  1st opp.party shifted the liability towards the 2nd opp.party that they are only responsible for settling claim application and the 2nd opp.party had already settled  all the remaining claims of the complainant as per the terms and conditions of the policy except the claim dated 19..5..2008 of Rs.34,923/-.  The 2nd opp.party had settled the other three claims by 3 different cheques.   This contention is supported by PW.1.   During his cross examination he deposed that  LlpUf\sf claim, policy iUic\F Lrkcgjv\vk\  rHdjujgkr\rk;  LfjrkSC,A  ejr\rJmk\ 3 claim sRy  payment TTK Health Service TO case  file svu\f SC,A Luv\vkrHdjuj}kn\mk\ 19;;5;;2008  H rHdju 34923 goeluksm  claim fkd  release svu\fj}jh\h;

Hence from the evidence the amount to be released is only the claim dated 19..5..2008 of Rs.34,923/-.  It can be seen that from Ext. P3 to P12 all the communications were made by the complainant to the 2nd opp.party for getting the claim amount.   That shows that 2nd opp.party is the responsible person for settling the claim amount.  1st opp.party’s case is that the complainant has not reported any claim with the 2nd opp.party for Rs.34,923/- dated 19..5..2008 and the 2nd opp.party is unaware  of the aforesaid claim.  But Ext.P11 and P12 clearly shows that the complainant had intimated the claim to the 2nd opp.party for Rs.34923/- dated 19..5..2008.  Hence the complainant is entitled to get the said amount.

On considering the entire evidence we are of the view that the 2nd opp.party is the responsible person to settle the claim of the complainant.   There is no deficiency in service on the part of opp.parties 1 and 3

In the result the complaint is allowed in part.  2nd opp.party is directed to pay Rs.34,903/- with 9% interest to the complainant.   2nd opp.party is also directed to pay Rs.5000/- as compensation and Rs.1000/- as cost to the proceedings.   The order is to be complied with within one month from the date of receipt of the order.

Dated this the 15th day of March, 2012

I n d e x

List of witnesses for the complainant

PW.1. – A. Shamsudeen

List of documents for the complainant

P1. – Policy No.2007/4841000223/22

P2. – Cheque No.634356 dated 2..4..2008

P3. – Letter dated 23..6..2008

P4. – Advocate Notice

P5. – Postal receipt

P6. – Acknowledgement card

P7. – Copy of Application

P8. – Claim application dated 19..5..2008

P9. – Claim application dated 16..6..2008

P10. – Claim application dated 9..7..2008

P11. – Postala receipt

P12. – Acknowledgement card.