By. Smt. Bindu. R, President:

            This complaint is filed by Aboobacker (Sidhique) and others against the Executive Director, Shreyas Social Service Centre and another alleging deficiency of service and unfair trade practice from the side of Opposite Parties.

            2.  The Complainants alleged that they are the beneficiaries of Policy No.P/181315/01/2014/000942 issued by Opposite Party No.2.   According to the Complainants they were insured with Opposite Party No.2 through Opposite Party No.1 and were treated in different hospitals for different diseases and lodged their claims in proper time with all details.  The Opposite Party No.2 even though received the claims lodged by the Complainants, not replied or paid the amount even after repeated demands from the Complainants.  The Opposite Party No.1 informed the Complainants that they had remitted the entire amount to the Opposite Party No.2 but the Opposite Party No.2 told that since the claims are of huge amount and hence they forwarded the matter to the higher authorities. But till date they have not settled the claims which amounts to deficiency of service and unfair trade practice from the side of the Opposite Parties and hence Complainants praying for issuing a direction to the Opposite Party No.2 to pay an amount of Rs.1,98,423/- with 18% interest from 01.08.2013 and for other reliefs.

            3.  Upon notice Opposite Parties entered into appearance and filed their separate versions.

            4. The Opposite Party No.1 admitting the policy issued by Opposite Party No.2 contented that Opposite Party No.1 is a social organization working among the people who are poor and marginal farmers, coolie workers and downtrodden people in the society.  According to Opposite Party No.1 the Opposite Party No.2 approached and requested for facilities to introduce the insurance scheme of Opposite Party No.2 to the public through the infrastructure of Opposite Party No.1 and Opposite Party No.1 provided sufficient facilities to the Opposite Party No.2 to interact with people who are interested to join the policy of Opposite Party No.2.  The claimants approached Opposite Party No.1 on 22.05.2015 with demand of claim amount offered by Opposite Party No.2.  The representative of Opposite Party No.1, along with representative of the Complainants approached Opposite Party No.2 in their office, but Opposite Party No.2 expressed their difficulty to process the claim since it is for huge amount.  According to the Opposite Party No.1, it is the bounden duty of the Opposite Party No.2 to settle the claim since they have accepted the premium.  Opposite Party No.1 contented that there is no deficiency of service or unfair trade practice from the side of Opposite Party No.1 and they are unnecessary party to the proceedings.   Opposite Party No.1 is not liable for any compensation and prayed for dismissal of the complaint with cost of Opposite Party No.1.

            5.  Opposite Party No.2 filed version stating that the petition is not maintainable and is liable to be dismissed.  According to Opposite Party No.2 even though all Complainants are the beneficiaries of policy No. P/181315/01/2014/000942 they are not having the same interest as per S12(1)(c) of Consumer Protection Act 1986.  The Opposite Party No.2 contented that all the Complainants have not lodged their claims in proper time and they do not have any common interest as the claim of each individuals were for different diseases and treatments were taken in different hospitals on different dates and hence the claims were repudiated on different grounds.  Moreover, the cause of action is also different.  The Complainant No.1 is also not authorized to lodge the complaint and hence Consumer Case is not maintainable.  The Opposite Party No.2 contented that they entered into a contract with Opposite Party No.1 based on the request of Opposite Party No.1 through mail dated 23.11.2012 and the Opposite Party No.2  designed a policy name Group Medi Claim Tailor Made Policy with customized features dated 20.01.2013 which has been accepted by the Opposite Party No.1.  Quote for the policy states the terms and conditions and other details of the policy.  The Opposite Party No.1 paid the premium to the Opposite Party No.2 and entered into a contract for covering the employees and their families as stated under the policy.  It is the case of the Opposite Party No.2 that proposal and prospectus along with 26 listed hospitals has been designed by Opposite Party No.2 with the approval of Opposite Party No.1 and submitted to the Opposite Party No.1 through an agent of Opposite Party No.2.  Proposal Form is the integral part of the insurance contract and the policy is issued strictly in accordance with the terms and conditions.  Being a health policy the Complainants are bound to give proper information regarding his present and past health status at the time of submitting proposal and the policy is issued after accepting the facts in the proposal form on utmost good faith.  The Opposite Party No.2 contented that the prospectus of the Group policy clearly states that for availing insurance benefits treatment must be taken from the listed hospitals which is available from the office of SHREYAS, the Opposite Party No.1.  It is also stated that the Company is responsible for denying or partially allowing the claim if treatment is taken from any other hospitals other than the listed hospitals and is subject to merit of the cases.  According to the Opposite Party No.2, there is no deficiency of service or unfair trade practice from the side of Opposite Party No.2 and the claims are repudiated based on terms and conditions.  The Opposite Party No.2 had issued the policy on good faith based on the declaration made by the insured in the proposal form which is the basis of the contract of insurance.  Opposite Party No.2 contented that the complaint is vexatious, frivolous for harassing the Opposite Parties with intention for getting unlawful enrichment from the Opposite Parties and hence prayed for dismissal of the complaint with compensatory costs.

            6.  The Opposite Party No.2 filed an additional version stating that based on the policy No.P/181315/01/2014/001288, P/181315/01/2014/000943 and P/181315/01/2014/002401 Opposite Party No.2 had collected the complete policy and claim details from the computer data.  In the additional version the Opposite Party No.2 had stated elaborately, the reason for repudiation of claim with Claim number and the liability (which is not admitted), upon Opposite Party No.2 in each case which is as follows:-

1)        Sainabha, W/o. 1^st Complainant Claim No.121830 was admitted in the hospital which is not a listed hospital on 23.09.2013 and was discharged on 24.09.2013, which was rejected.  After discharge the Complainant filed claim for reimbursement.  The liability (not admitted) as per terms and conditions come to Rs.825/- only.

2)        Sainabha, W/o. 1^st Complainant, Claim No.155138 for which the company received only intimation.  No documents or claim filed by the Complainant.

3)        Padmaja Sukumaran, W/o. 2^nd Complainant with Claim No.200665 was admitted in the hospital which is not a listed hospital on 10.01.2014 and was discharged on 16.01.2014. The liability (not admitted) as per terms and conditions come to Rs.12,000/- only.

4)        Francis, 3^rd Complainant, Claim No.75118 was admitted in the hospital on 29.04.2014 and was discharged on 01.05.2014. The liability (not admitted) as per terms and conditions come to Rs.1,780/- only.

5)        Minnu, D/o. 4^th Complainant, Claim No.166505 was admitted in the hospital which is not a listed hospital on 22.11.2013 and was discharged on 24.11.2013. The liability (not admitted) as per terms and conditions come to Rs.1,125/- only.

6)        Minnu, D/o. 4^th Complainant (as mentioned in the version) Claim No.193914was admitted in the hospital, which is not a listed hospital on 31.12.2013 and discharged on 01.01.2014, which was rejected. After discharge the Complainant filed claim for reimbursement.  The liability (not admitted) as per terms and conditions come to Rs.825/- only.

7)        Lakshmikutty, M/o. 5^th Complainant, Claim No.192129 was admitted in the hospital which is not a listed hospital on 28.12.2013 and was discharged on 13.01.2014, which was rejected. After discharge the Complainant filed claim for reimbursement.  The liability (not admitted) as per terms and conditions come to Rs.20,250/- only.

8)        Nevin Nehanth, S/o. 6^th Complainant, Claim No.95047was admitted in the hospital which is not a listed hospital on 23.07.2014 and was discharged on 24.07.2014, which was rejected. After discharge the Complainant filed claim for reimbursement.  The liability (not admitted) as per terms and conditions come to Rs.1,904/- only.

9)        Aseena, W/o. 7^th Complainant, Claim No.141240(163863) was admitted in the hospital which is not a listed hospital on 18.10.2013 and was discharged on 19.10.2013, which was rejected. After discharge the Complainant filed claim for reimbursement.  The liability (not admitted) as per terms and conditions come to Rs.780/- only.

10)      Valsa, W/o. 8^th Complainant Claim No.241190 was admitted in the hospital which is not a listed hospital on 10.03.2014 and was discharged on 18.03.2014, which was rejected. After discharge the Complainant filed claim for reimbursement.  The liability (not admitted) as per terms and conditions come to Rs.13,500/- only.

11)      Melbin, S/o. 9^th Complainant, Claim No.121357 was admitted in the hospital which is not a listed hospital on 23.09.2013 and was discharged on 26.09.2013, which was rejected. After discharge the Complainant filed claim for reimbursement.  The liability (not admitted) as per terms and conditions come to Rs.3,330/- only.

12)      Shena Binu, W/o. 10^th Complainant with claim No.145223 was admitted in the hospital on 05.10.2013 and was discharged on 09.10.2013.  No other details are given in the additional version.  But in chief affidavit it is stated that after discharge the Complainant had filed claim form for reimbursement.  On perusal of records it is confirmed that the Complainant had not intimated the hospitalization in time ie within 24 hrs from the date of admission, the claim was rejected by Opposite Party No.2 on the ground “violation of Condition No.2 & 3 of the policy”.  But it is stated that the liability (not admitted) as per the terms and conditions comes to Rs.3,537/- only.

13)      Nafeesa, M/o. 11^th Complainant with claim No.137546 was admitted in the hospital on 19.09.2013 and was discharged on 23.09.2013.  After discharge the Complainant filed claim form for reimbursement which was rejected for the reason violation of Condition No.2 & 3.  According to Opposite Party No.2, the liability (not admitted) as per the terms and conditions comes to Rs.4,720/- only.

14)      Nafeesa, M/o. 11^th Complainant was admitted in the hospital which is not a listed hospital on 01.10.2013 and was discharged on 08.10.2013. After discharge the Complainant filed claim for reimbursement which was rejected.  According to Opposite Party No.2 the liability (not admitted) comes to Rs.7,200/- only.

15)      Santha George, 12^th Complainant with Claim No.121915 was admitted in the hospital which is not a listed hospital on 12.09.2013 and was discharged on 13.09.2013. After discharge, the Complainant filed claim for reimbursement which was rejected.  According to Opposite Party No.2 the liability (not admitted) comes to Rs.750/- only.

16)  Mary John, 13^th Complainant with Claim No.147938 was admitted in the hospital which is not a listed hospital on 10.10.2013 and was discharged on 13.10.2013. After discharge, the Complainant filed claim for reimbursement which was rejected.  According to Opposite Party No.2 the liability (not admitted) comes to Rs.1,853/- only.

17)  With reference to the 14^th Complainant with Claim No.184483 the Opposite Party No.2 has received only intimation.  No claim files or documents were filed by the Complainant.

18)  Sreeja, 15^th Complainant with Claim No.173052 was admitted in the hospital which is not a listed hospital on 23.11.2013 and was discharged on 26.11.2013. After discharge, the Complainant filed claim for reimbursement which was rejected.  According to Opposite Party No.2 the liability (not admitted) comes to Rs.17,250/- only.

19)  Sheeja Shaji, 16^th Complainant, had not submitted the Claim number of other details and Opposite Party No.2 had not received any document.  But according to Opposite Party No.2, the liability (not admitted) comes to Rs.2,575/- only.

7.  Thus according to Opposite Party No.2 if the Commission finds any liability upon this Opposite Party, then the liability to be limited to Rs.91,629/- in the above mentioned 19 claim files.  The Opposite Party No.2 submitted that the Complainants are not entitled to get any reliefs claimed and there is no deficiency of service from the side of Opposite Party No.2 and hence prayed for dismissal of the complaint with compensation and costs to Opposite Party No.2.

8.  Evidence in this case consists of the oral evidence of PW1 and Ext.A1 from the side of Complainant and oral evidence of OPW1 and Ext.B1 to B35 series from the side of Opposite Parties.

9.  The following are the questions to be analyzed.

1)        Whether the complaint is maintainable before the Commission?

2)        Whether the Complainants had sustained to deficiency of service or unfair trade practice from the side of the Opposite Parties?

3)        If so, the compensation and costs for which the Complainants are entitled to get?

10. Heard both sides.  As per Order dated 18.05.2023 in I.A.254/2023 Joint Trial was allowed with respect to 9 cases Viz C.C.159/2015, C.C.164/2015, C.C.167/2015, C.C.168/2015, C.C.169/2015, C.C.170/2015, C.C.178/2015 C.C.179/2015, and C.C.180/2015.  But at the time of evidence, Opposite Party submitted that there are some differences and hence separate evidences are to be taken.

11.  The Commission had made a thorough examination of the overall aspects of the case and perused all documents produced from either side. It can be seen that the Opposite Party No.2 had designed a policy viz Group Medi Classic Tailor Made Policy and introduced the same through Opposite Party No.1 with respect to different families and members and the Opposite Party No.1 had collected and paid the premium to the Opposite Party No.2 which is not being denied by both Opposite Parties.  The Complainants in the instant case had paid consideration to the Opposite Parties which is very clear and is admitted by the Opposite Parties in their version.  Since the Complainants had paid consideration and Opposite Parties had accepted the same,  the Complainants are coming under the purview of the term “Consumer” as per S.2(1)(d) of the Consumer Protection Act 1986 and Point No.1 is found in favour of the Complainants and therefore the complaint is maintainable before this Commission.

12.  The main contention of Opposite Party No.2, in repudiating the claim in most of the cases are due to the reason that the claimants were not treated in the listed hospitals of Opposite Party No.2.  Another contention is that the Complainants were treated for different diseases and the third allegation is that all the Complainants in this case do not have a common interest and the relation of the aggrieved parties to the Complainants are not mentioned in the complaint.  In order to sum up and evaluate the contentions raised above, the Commission assessed all the factors together for brevity.

13.  The allegation of the Opposite Party No.2 that each and every Complainant is having different interests shall not survive since the interests of the Complainants are of a common nature ie to get the insured amount.  The allegation that they were treated for different diseases shall also will not lie since the policy itself was introduced for the downtrodden of the society after accepting the premium from them making them believe that they will be getting insurance coverage for hospital treatment. Withdrawing from such a promise is a very clear case of unfair trade practice from the side of the Opposite Party No.2.

14.  The argument of the Opposite Party No.2 that the relation of the Complainant to the other Complainants do not have any significance since such a condition is not laid down in the Consumer Protection Act.  It is proved with evidences that the Opposite Party No.2 had approached the Complainants through Opposite Party No.1 and insured them after obtaining premium and thereafter repudiated their claim without valid reasons saying either that they have not undergone the treatment in the listed hospitals or raising some other flimsy grounds which amounts to deficiency of service and unfair trade  practice from the side of the Opposite Party No.2.  This is a clear case as can be seen from the records that the innocent consumers who were not aware of the hidden conditions were exploited by offering different benefits and subsequent withdrawal which is a case to be warranted.  Moreover even though Opposite Party No.2 submitted that the lists of hospitals are given to the Complainants at the time of issuance of policy, through Opposite Party No.1, the said statement is denied both by the Complainants and Opposite Party No.1.  According to Opposite Party No.1 no list of hospitals are given to Opposite Party No.1 and it is the argument of the Complainant that the list of hospitals produced by Opposite Party No.2 are fraudulently created for the purpose of the case.  The Opposite Party No.2 could not prove that the list of hospitals is given to the Parties at the time of issuing the policy itself, and thereby the Complainants had violated the policy condition.

15.  Considering the circumstances and documentary evidences into account Opposite Party No.1 is exempted from the liability of payment of amount since Opposite Party No.1 stands only as a mediator and hence the following Orders are passed.

1. The Opposite Party No.2 is directed to pay an amount of

Rs.1,98,423/- (Rupees One Lakh Ninety Eight Thousand Four Hundred and Twenty Three Only) with 6% interest from 01/08/2013 till the date of realization.

   2)     The Opposite Party No.2 shall pay an amount of Rs.32,000/- (Rupees Thirty Two Thousand Only) towards compensation to the Complainants.

  3)      The Opposite Party No.2 shall be liable for an amount of Rs.16,000/- (Rupees Sixteen Thousand Only)  towards costs of the proceedings.

Needless to say that the above ordered amount shall be paid by Opposite Party No.2 within 30 days of receipt of copy of this Order otherwise the Opposite Party No.2 shall be liable for 9% interest for the amount from the date of Order till date of realization except for the amount that is awarded as costs.

The Opposite Party No.2 is at liberty to deduct the amount if any paid to the Claimants as part of settlement.

In the case of those Claimants who has not filed the details for the claim so far shall file the required details before Opposite Party No.2.

Hence complaint is allowed and the pending applications if any stands closed.

Dictated to the Confidential Assistant, transcribed by him and corrected by me and pronounced in the Open Commission on this the 27^th day of September 2024.

Date of Filing:- 13.06.2015.

PRESIDENT   : Sd/-

MEMBER       : Sd/-

APPENDIX.

Witness for the Complainant:-

PW1.              Sukumaran.                                                 Coolie.

Witness for the Opposite Parties:-

OPW1.          Manu Mohan.                                             Assistant Manager, Claims.

Exhibits for the Complainant:

A1.                  Authorization Letter.                                            Dt:31.05.2015.

Exhibits for the Opposite Parties:-

B1.                  Copy of Group Mediclaim Tailor Made Policy.

B2.                  Copy of List of Hospitals.

B3(a).             Discharge Summary.

B3(b).                        Claim Form for  Medical Insurance.

B4.                  Copy of Repudiation Letter.                                Dt:24.12.2013.

B5(a).             Discharge Summary.

B5(b).                        Claim Form for  Medical Insurance.

B6.                  Copy of Repudiation Letter.                                Dt:11.02.2014.

B7(a).             Discharge Summary.

B7(b).                        Claim Form for  Medical Insurance.

B8.                  Copy of Repudiation Letter.                                Dt:29.07.2014.

B9(a).             Discharge Summary.

B9(b).                        Claim Form for  Medical Insurance.

B10.               Copy of Repudiation Letter.                                Dt:24.01.2014.

B11(a).          Discharge Summary.

B11(b).          Claim Form for  Medical Insurance.

B12.               Copy of Repudiation Letter.                                Dt:05.02.2014

B13(a).          Discharge Summary.

B13(b).          Claim Form for  Medical Insurance.

B14.               Copy of Repudiation Letter.                                Dt:04.03.2014.

B15(a).          Discharge Summary.

B15(b).          Claim Form for  Medical Insurance.

B16.               Copy of Repudiation Letter.                                Dt:05.02.2014

B17(a).          Discharge Summary.

B17(b).          Claim Form for  Medical Insurance.

B18.               Copy of Repudiation Letter.                                Dt:23.01.2014

B19(a).          Discharge Certificate

B19(b).          Claim Form for  Medical Insurance.

B20.               Copy of Repudiation Letter.                                Dt:28.06.2014.

B21(a).          Discharge Summary

B21(b).          Claim Form for  Medical Insurance.

B22.               Copy of Repudiation Letter.                                Dt:16.12.2013.

B23(a).          Discharge Summary

B23(b).          Claim Form for  Medical Insurance.

B24.               Copy of Repudiation Letter.                                Dt:14.01.2014

B25(a).          Discharge Summary

B25(b).          Claim Form for  Medical Insurance.

B26.               Copy of Repudiation Letter.                                Dt:04.12.2013.

B27(a).          Discharge Summary

B27(b).          Claim Form for  Medical Insurance.

B28.               Copy of Repudiation Letter.                                Dt:04.12.2013.

B29(a).          Discharge Summary

B29(b).          Claim Form for  Medical Insurance.

B30.               Copy of Repudiation Letter.                                Dt:04.12.2013.

B31(a).          Discharge Summary

B31(b).          Claim Form for  Medical Insurance.

B32.               Copy of Repudiation Letter.                                Dt:16.12.2013.

B33(a).          Discharge Summary

B33(b).          Claim Form for  Medical Insurance.

B34.               Copy of Repudiation Letter.                                Dt:04.12.2013.

B35.               Authorization Letter.                                            Dt:20.03.2021.

PRESIDENT   :Sd/-

MEMBER       :Sd/-

/True Copy/

Sd/-

                                                                                             ASSISTANT REGISTRAR

                                                                                                  CDRC, WAYANAD.

Kv/-