CONSUMER DISPUTES REDRESSAL FORUM,PALAKKAD

Dated this the 1^st  day of January 2015

PRESENT :  SMT.  SHINY. P.R, PRESIDENT

               :  SMT. SUMA. K.P, MEMBER                     Date  of filing : 10/10/2013

CC /170/2013

Achuthaprasad.M.V

S/o.Karunakarawarier,

Residing at Pathirakodekalam,                                  :        Complainant

Karippode P.O, Chittur, Palakkad.

(By Adv.M.P.Ravi )

                                                           Vs

1. The Manager,

    M/s.National Insurance Co.Ltd.,

    2^nd Floor Kanoos East Fort Maidan,                                

    Kunnathurmedu, Palakkad – 678 013.

    (By Adv.P.K.Devadas )

2.  The Manager,

     M/s.T.T.K.Health Care Services Pvt.Ltd.,

     39-4130 1^st Floor Marina Builfing,                       

     M.G.Road, Ernakulam – 682 016.

3.  Branch Manager,

     M/s.National Insurance Co.Ltd,                             :        Opposite parties

     1^st Floor, Shanthi Park N.H.49, Kolenchery.

     (By Adv.P.K.Devadas )

4.  Secretary,

     Kerala Advocates Clerks Welfare Fund Committee ,

     TC 26/580(1)SERA24, Thiruvananthapuram.

5.  LMB Insurance Brokers (P) Ltd.,

     Insurance Park, Perumal Buildings,

     T.C.38/971, Power House Road,

     Chalai (PO), Thiruvananthapuram – 695 036.

O R D E R

By Smt. Suma. K.P, Member,

Brief case of the complaint :-

          The complainant is an Advocate Clerk having membership in the Kerala Advocates’  Clerks  Welfare Fund Committee, Thiruvananthapuram.  His membership No. is 09/KACWFC/30/2004.  The members of the welfare fund are provided with Mediclaim benefits and the 1^st opposite party has issued a policy covering the mediclaim.  The 1^st opposite party has also issued a health card bearing number KOC-NC-K0260-000-0003596-A.  The 1^st opposite party has engaged the 2^nd opposite party to settle the claims.  The complainant’s mother had undergone eye surgery on 19/8/2010 and 20/08/2010 at Sai Nursing Home, Palakkad.  The complainant has preferred a claim of Rs.10,958.27/- on 31/08/2010 for the reimbursement of the expenses incurred through the Unit Secretary, Advocate Clerks Association, Palakkad to the Welfare Fund Committee, Thiruvananthapuram.  The said file was sent to the opposite parties on 9/9/2010 as per file No.1516/KACWFC/2010 .   So far the opposite party have not settled the claim or has issued any communication regarding the status of the said claim.  Finally the complainant has issued a letter dated 14/08/2012 to the 2^nd opposite party to settle the claim immediately, which was duly received by the opposite party on 17/08/2012.  So far the opposite party has not settle the claim or the complainant.  The complainant alleges that the acts of the opposite parties are against law and against the conditions stipulated in the policy which amounts to clear deficiency of service.  The tactics of not settling the claim or not giving any reply inspite of repeated requests made by the complainant by the opposite parties amounts to unhealthy trade practice.  Hence the complainant had approached before the Forum seeking compensation of Rs.50,000/- for the deficiency of service on the part of the opposite parties. 

Notice was issued to the opposite parties for appearance. 1^st and 2^nd opposite party entered appearance and filed their respective version. 1^st opposite party admitted that complainant is a member of Group Mediclaim Policy insured in the name of Kerala Advocates’ Clerks Welfare Fund Committee.  They contented that they had not received any claim form the complainant or anyone else regarding the subject matter of the complaint.   1^st opposite party denied the averment in the version filed by 2^nd opposite party that the complainant’s mother was  insured with 1^st opposite party.  The policy issuing branch is M/s.National Insurance Co.Ltd, 1^st Floor, Shanthi Park N.H.49, Kolenchery.  Hence they had to be impleaded in the party array for proper adjudication of the matter.  

Complainant filed petition for impleading supplemental 3^rd opposite party .  3^rd opposite party entered  and filed version.  Complainant filed another petition for impleading supplemental 4^th opposite party. 4^th opposite party  entered appearance through authorized person and filed their version contending the following.  As a part of various benefits provided to the members, Advocates’ clerks of the fund, medical benefits was also provided. During the period of 1/1/2007 to 31/12/2010, a Group Medical-cum Personal Accident Policy was implemented for the members of the fund on the basis of a tripartite agreement executed by the 4^th opposite party (Kerala Advocates’ Clerks Welfare Fund Committee) as 1^st  party  with National insurance company Ltd. as 2^nd party and the LMB insurance Brokers Pvt.Ltd as a 3^rd party.

As per the agreement the 1^st party had to pay the premium amount and purchase the policy from the 2^nd party during the scheme period and 3^rd party had to render all insurances related services during the currency of the scheme period.  The complainant who is a member of this welfare fund had preferred a medical claim for Rs.10,958/- incurred for the medical treatment of complainant’s mother, Smt.Sarojini Warrassiar on 31/8/2010.  As per the terms of the tripartite agreement the 1^st opposite party are bound to settle the claim with the assistance of the LMB Insurance Brokers Pvt.Ltd.  Accordingly the 4^th opposite party on 9/9/2010, had forwarded entire file containing the claim for settlement, as per the terms of the agreement to the 3^rd party of the agreement (LMB Insurance Brokers Pvt.Ltd).  It was submitted that since various applications for medical claims was forwarded to the insurance company where kept pending without sanctioning the claims, the 4^th opposite party addressed the 1^st opposite party to settle the claims within the stipulated period.  In response to this letter, the 3^rd party to the agreement ( LMB Insurance Brokers Pvt.Ltd) replied on 7/4/2012 noting that “Appv-Cheque not received from TPA” with regard to the claim of the complainant.  This was communicated to the complainant on 5/5/2012.  It was also contented that as per the terms of the agreement the medical insurance claim was in operation for an year from the date of payment of premium.  Since the Insurance Companies charge huge amounts as premium, the committee of the 4^th opposite party on 31/12/2010 resolved not to renew the tripartite agreement and to pay the medical claim directly by them there from.  There is no lapse from the part of the 4^th opposite party in forwarding the claim file to the insurance brokers. 

Complainant filed another petition to implead the  LMB Insurance Brokers Pvt.Ltd as supplemental 5^th opposite party.  Petition was allowed and notice was issued to the 5^th opposite party.  Notice returned unserved.  Complainant filed application to delete supplemental 5^th opposite party from the party array. It was stated that as per the documents filed by supplementary 4^th opposite party, the role of supplementary 5^th opposite party was over and  hence they are not a necessary party.  Opposite party filed counter stating that the documents produced by supplemental 4^th opposite party is only a photocopy and it is not proved and only  5^th opposite party is in a position to say where the relevant file is.  Hence they are necessary party.  After hearing the matter the forum finds that the claim already processed by supplemental 5^th opposite party and the details having furnished to supplemental 4^th opposite party. Hence the petition was allowed and the 5^th opposite party was deleted from the party array.  Complainant as well as opposite party 1 & 3 filed chief affidavits. Ext.A1-A4 was marked from the part of the complainant for which Ext.A2 series was marked with objection.  Complainant was cross examined as PW1 and 1^st opposite party was examined as DW1. The  Evidence was closed and matter was heard.  

The following issues are to be considered.

          1.   Whether there is any deficiency in service from the part of opposite

                parties?

          2.   If so, what is the reliefs and cost? 

 ISSUES 1 & 2

          It is obvious from Ext.A1 that complainant is a member of Advocates’ Clerks welfare Fund Committee, Thiruvananthapuram.  The letter given by the 4^th opposite party which was marked as Ext.A4 shows that the approved cheque was            not received from 2^nd opposite party.  The 1^st and 3^rd opposite party states that the evidentiary value of Ext.A4 cannot be looked into, since it is only a photocopy.   The 1^st opposite party submits that they are not aware of any communication the complainant had which 2^nd opposite party or anything sent by the complainant to 2^nd opposite party.  They admit that 2^nd opposite party is their Third Party Administrator.  If there was any latches on the part of 2^nd opposite party 1^st opposite party is not answerable.    1^st opposite party also contended that unless and until the claim of the complainant with supporting documents is not before them they are not in a position to say anything about it or initiate the settlement of that claim.  It is understood from the version filed by 4^th opposite party that they have forwarded the entire file to LMB Insurance Brokers Pvt.Ltd.  The averment in the version filed by 4^th opposite party that they have communicated to the complainant about the non receipt of approved cheque from TPA with regard to his claim through a letter No.487/KACWFC/2012 dated 5/5/2012.  The complainant had also mentioned about this letter and was produced and was marked as Ext.A4.  In version filed by 2^nd opposite party they had admitted that they have also received this letter and this letter actually pertains to a different claim of the same person i.e., Mrs.Sarojini Amma for admission and treatment undergone for diabetes, Hypertension and CVA at Thankam Hospital, Palakkad, which was later settled by them vide cheque No.20188 dtd.30/12/2010 for Rs.6,326/-. During cross examination complainant has admitted the receipt of this amount.  The complainant submits that the claim settled was in respect of an earlier claim submitted by the complainant.  Regarding the present claim the letter issued by the 4^th opposite party (Ext.A4) will go to show that the claim is not settled and the same is pending as on 07/04/2012. 1^st opposite party submits that without the original claim form and the documents it is not possible to settle the claim. The 4^th opposite party submits that they have forwarded the entire file to LMB Insurance Brokers Pvt.Ltd.  as per the agreement entered into by them. Since 1^st opposite party is also a party to the tripartite agreement they are also equally liable to settle the claims.  As per Ext.A4 it s evident that the complainant’s claim is already processed and the approved cheque is  not received from TPA.  Hence 1^st opposite party ought to have made necessary arrangements for issuance of approved cheque.  They cannot escape from their liability by merely stating that the entire file is not before them.  Without doing so, opposite parties have committed deficiency of service.  Hence the complaint is allowed.  In the above context, we direct 1^st opposite party to settle the claim of complainant, as per the norms and make necessary arrangements for the speedy delivery of approved cheque.  We also direct the 1^st opposite party to pay an amount of Rs.2,000/- (Rupees Two thousand only) as compensation for the mental agony suffered by the complainant. The complaint is disposed of accordingly.  The aforesaid amount shall be paid within one month from the date of receipt of this order failing which the complainant is entitled to get 9% for the claim amount from the date of order till realization. 

Pronounced in the open court on this the 1^st  day of January 2015

                                                                   Sd/-

                                                                   Smt. Shiny. P.R

                                                                     President                                                                                                                                         

                                                                       Sd/-                                                                                                         Smt. Suma. K.P

                                                                         Member

                                                A P P E N D I X

Exhibits marked on the side of complainant

Ext.A1- Insurance Card issued by the OP(Photocopy)

Ext.A2- Photocopies of Medical bills issued from Sai Nursing Home, Olavakkode dtd.20/08/2010l

Ext.A3- Notice sent by the complainant with ack.card dtd 14/08/2012

Ext.A4- Letter issued from the advocates’ clerk welfare committee, TVM

Exhibits marked on the side of opposite parties

Nil

Witness marked on the side of complainant

PW1   - Achuthaprasad.M.V

Witness examined on the side of opposite parties

DW1- Anil George.M

Cost Allowed

No cost allowed.