DATE OF FILING :28/09/16 

IN THE CONSUMER DISPUTES  REDRESSAL FORUM, IDUKKI

Dated this the 28th  day of  September 2018

Present :

SRI. S. GOPAKUMAR PRESIDENT

           SRI. BENNY. K. MEMBER

CC NO. 272/2016

Between

Complainant       :  Gracy Alias Jessy,

                                                                            Parambil House,

                                                                            Murickassery P.O.,

                                                                            Vathikudy Village,

                                                                             Idukki Taluk, Idukki District.

(By Adv: George Thomas)

And

Opposite Party                                : 1 . The Secretary,

                                                                   Murickassery Ksheerolpadaka Sahakarana 

                                                                                                                       Sangam Ltd.,

                                                                   No.124 (D) Apcos,

                                                                   Murickassery P.O., Idukki District.

                                                              2 . The Divisional Manager,

                                                                    The Oriental Insurance Company Limited,

                                                                    Divisional Office No.V, 1st  Floor Shan Complex, 

                                                                    Bazar Road, Mattanchery, Kochi – 682 002.

                                                                   (By Adv: K.Pradeepkumar)

                                                              3 . The Managing Director,

                                                                  Ernakulam Meghala Ksheerolpadaka Union Ltd., 

                                                                    E 150 (D) (Milma Ernakulam Union), 

                                                                    Elappilly P.B.No. 2212, Kochi 682 024.

 

O R D E R

SRI. S. GOPAKUMAR (PRESIDENT)

 

The case  of the complainant is that,  

 

Complainant is a cattle rearer, and an active member of the society APCOS 1 24(D).  The first opposite party is the society and second opposite party is an insurance company having a tie up with Milma, the mother concern of the first opposite party Society.  Complainant took an insurance policy from the  second  opposite  party  by  paying  Rs.795/-  as  premium  and  the  policy

                                                                                                                          (Cont.....2)

-2-

renewed till 2014-15.  On 04/03/14, the husband of the complainant fell down from a ladder and suffered  serious injuries like fracture on back bone and dislocation of vertebral bone.  He was  admitted MOSC, Medical College, Kolenchery and treated there as an inpatient for a long period and an amount of Rs.3.5 Lakhs spent for his treatment alone.  As a family protection insurance policy holder, complainant submitted relevant medical bill to the first opposite party, and the first opposite party forwarded a medical claim with medical records and medical bills having an amount of Rs.1,71,398/- before the second opposite party, insurance company on 06/04/14 with proper recommendations.  But the opposite party denied to reimburse the medical expenses and the act of the opposite parties are gross deficiency in service and unfair trade practice.  Hence the complainant filed this petition against the opposite parties for getting the relief such as to direct the opposite parties to reimburse the medical expenses of Rs.1,71,398/- along with compensation and cost.

 

Opposite parties entered appearance and filed reply version separately.

 

In their version the first opposite party contented that the complainant is the member of the society and they insured all the members of the society including complainant who is having membership number 917, and renewed her membership.  The executive committee decided to renew insurance policy of all the member during the period of 2013-2014 and they forwarded all the documents along with insurance premium and list of policy holder in time, and they produced their copy of their documents along with the reply version for perusal.  The opposite parties further contented that they completed all the formalities of renewing the insurance policy of their members, in time and there is no deficiency of service was happened on the part of this opposite party and is liable to be exempted from this matter. 

 

In their reply version the second opposite party contented that, as on the date of accident, there was no insurance contract for the coverage of complainant and her family.  Further they admitted that the opposite parties had a group insurance scheme with Milma, Ernakulam Region, for a coverage of its members.  But premium for renewal of complainant's policy was not received in time.  Hence there was a break in the policy.  As on the date of accident the opposite parties had no insurance contract for the coverage of the

                                                                                                                          (Cont.....3)

-3-

complainant's family.  Hence complainant is not entitled to receive any benefit under the group insurance scheme.  Opposite parties further contented that even if it is found that complainant's family is entitled to the insurance benefit of the group insurance scheme mention above, the opposite partt's liability if any is limited to Rs.20,000/- per incident at a time.

 

Evidence adduced by the complainant by way of proof affidavit and documents.  Complainant was examined as PW1.  Ext.P1 and Ext.P2 were marked.  Ext.P1 is the copy of register of membership and Ext.P2 is the copy of personal milk purchase report.

 

From the opposite side the first opposite party's side the first opposite party produced some documents and marked as Ext.R1 to Ext.R3.  Ext.R1 is the copy of application form of Kissan Karshaks Aarogya Suraksha Paddathi, Ext.R2 is the copy of minutes of the society dated 22/03/13, Ext.R3 is the copy of claim application of covering letter of the first opposite party along with copy of bills dated 06/04/14.

 

Heard both sides,

 

The point that arose for consideration is whether there is any deficiency in service from the part of opposite parties, and if so, for what relief the complainant is entitled to ?

                                                                  

The Point:- We have heard the counsels for both sides and gone through the evidence on record.  On going through the averment in the complaint and reply version of the opposite parties, Forum found that, it is an admitted fact that the first opposite party society has forwarded the claim application of its member including the complainant.  For  convincing their version the first opposite party produced copies of claim form, their recommendation letter  also the first opposite party produced the copy of minutes of the General Body Ext.(R3).  On perusing these documents, it is seen that the Managing Committee of the first opposite party convened on 22/02/13 decided to forward the Group Insurance application along with its premium.  As per this decision taken by the Managing  Committee of the first opposite party  they forwarded insurance application of their members along with a total premium of Rs.14825/-.   To  counter  these averment the second opposite party had not

                                                                                                                          (Cont.....4)

-4-

produced any evidence.  In their reply version the second opposite party stated that at the time of accident of the husband of the complainant, there was no valid insurance coverage because the premium for renewal of complainant's policy was not received in time.  In their version the second opposite party further contented that if it is found that complainant's family is entitled to the insurance benefit of the group insurance scheme, this opposite party's liability if any is limited to Rs.20,000/- per incident at a time.

 

Here opposite parties denied the claim duly forwarded by the first opposite party to the second opposite party with their recommendation letter, on the ground that at the time of the accident complainant's premium for renewal was not received to them.  Here it is very pertinent to note that as per the evidence on record it is admitted that, the first opposite party society forwarded the claim from 2011 onwards as a group insurance, for these members and their family.  No independent insurance policy was taken.  No independent premium was remitted.  More over even though the second opposite party denied the receipt of the premium of the complainant, they failed to produce the list of other members which was forwarded by the first opposite  party as per Ext.R1 to convince the Forum that except the complainant other members premium was collected from the first opposite party.  Here mere denial is not sufficient to repudiate a lawful claim.  More over no copy of insurance policy  is produced by the second opposite party, to establish  their version.  Hence the Forum cannot justify the repudiation of this medical claim.

 

On  perusal of Ext.R3 series, Forum convinced that complainant's husband Jose caused injuries due to the fall from a ladder on 04/03/14 and admitted in MOSC, Kolenchery as inpatient and the complainant had to spent Rs.1,71,398/- expenses (Bills attached).  Even though from the side of the complainant and the first opposite party produced some documents, to prove that, at the time of accident there was valid insurance coverage, to the complainant and her family.  But neither the complainant  nor the opposite parties failed to produce necessary documents to convince the Forum that  to what extent the policy will cover.  Whether the policy covers whole medical expenses or to a limited amount.  Absence of specific evidence relating to the medical coverage or accidental coverage, Forum is not in a position to grant all medical expenses as such.

                                                                                                                          (Cont.....5)

-5-

Hence on the basis of the above discussion, the Forum is of a considered view that the complainant and his family was the policy holder of the second opposite party insurance company since 2011 and the first opposite party society renewed their policy in the year 2013-2014, and the second opposite party company is bound to compensate the complainant to some extent.  Hence the complaint allowed in part.  The second opposite party is directed to pay an amount of Rs.1 Lakh as medical claim to the complainant within  30 days from the date of receipt of the copy of this order, failing which this amount shall carry 12% interest per annum from the date of default  till the realization. 

 

Pronounced in the Open Forum on this the 28th day of September, 2018.

 

                                                                                                      Sd/-

                                                                                      SRI. S. GOPAKUMAR (PRESIDENT)

                                                                                                             Sd/-                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 

             SRI. BENNY. K.  (MEMBER)

 

APPENDIX

Depositions :

On the side of the Complainant :

PW1               - Grassy

On the side of the Opposite Party :

Nil

Exhibits :

On the side of the Complainant :

Ext.P1            -  The copy of register of membership

Ext.P2            -  The copy of personal milk purchase report

On the side of the Opposite Party :

Ext.R1      -  The copy of application form of Kissan Karshaks Aarogya Suraksha 

                     Paddathi,

Ext.R2      -  The copy of minutes of the society dated 22/03/13

Ext.R3      -  The copy of claim application of covering letter of the first opposite 

                     party along with copy of bills dated 06/04/14.

 

                     Forwarded by Order,

 

 

                           SENIOR SUPERINTENDENT