DISTRICT CONSUMER DISPUTES REDRESSAL FORUM,

Palakkad, Kerala

Dated this the 3^rd day of November, 2011

Present : Smt.Seena.H. President

: Smt.Preetha G Nair, Member

: Smt.Bhanumathi A.K, Member

Date of filing: 13/08/2010

CC/103/2010

C. Chandran,

S/o Late V.S.K Nair,

L 4/99, KSHB Colony, - Complainant

Kallepully (P.0),

Palakkad

(By Adv. S. Sivadas)

Vs

1. The Senior Manager (Personal),

Final Settlement Section,

46, Old Administrative Building,

Bhilai Steel Plant,

Bhilai- 490 001.

- Opposite parties

2. The Manager,

MD India Health Care Services,

(TPA) Pvt Ltd,

1402, 15^th Main Road,

Anna Nagar,

Chennai- 600 040.

(By Adv. C. B. Anand)

3. The United India Insurance Co. Ltd,

Divisional Office-XI,85,

Himalaya House, 8^th Floor,

K.G. Marg, New Delhi-110001

(By Adv. K. Lakshminarayanan)

(Amended as per order in I.A. 2/2011 dated 4/1//2011)

O R D E R

By Smt. Bhanumathi. A. K, Member

The complainant is a retired employee from Bhilai Steel Plant under the SAIL in the year 1994. At the time of retirement there was an option given to employees either to avail an amount for medical benefit year to year or to opt for Group Mediclaim Scheme for the retired employees and their spouses as there was no pension for the retired employees at that time. If the retiring employee opts for Group Mediclaim Insurance Scheme he will have to pay the requisite amount to the I^st opposite party every year towards renewal of the policy. The complainant is a member of the scheme from 1994 onwards and he was making the mediclaim membership fee every year from Palakkad for himself and his wife. The renewal for the year 2010 was also been made from Palakkad and he was allotted a MIN No:1201108. The members of the scheme is covered through Group Insurance Mediclaim Policy supplimentary III^rd opposite party and the member will have to opt a TPA centre for the purpose of claim settlement. The complainant has opted the II^nd opposite party as the opted centre for claim settlement for him. As per the scheme the policy covers the reimbursement of Hospitalisation charges and / or Out Patient Department expenses for illness / diseases contracted or injury/ sustained by insured persons and in the event of any claim the II^nd opposite party will pay the insured members reimbursement of actual charges up to Rs. 2,00,000/- per member for doctor fee, medicines, room etc. and Rs. 5,000/- for Out Patient Department for persons who have completed 70 years as on 30/12/2009. For getting the claim for hospitalisation the member will have to admitted in a hospital for a minimum period of 24 hours.

The complainant had undergone treatment at Malabar Hospital, Palakkad for treatment of left eye, but the vision of the left eye was not fully restored. The doctor referred the complainant to M/s Sankara Eye Centre, Coimbatore and an amount of Rs. 12,425/- has been spent for retina treatment. In Malabar Hospital the complainant spent an amount of Rs. 2,827/-. Altogether the complainant spent an amount of Rs. 15,242/-. After the out patient department treatment and hospitalisation the complainant sent all the original medical bill and necessary documents to II^nd opposite party and the II^nd opposite party has received the same.

But the II^nd opposite party has reimbursed only an amount of Rs. 2827/- vide cheque No: 24880 dated 12/05/2010. Balance amount of Rs. 12,425/- spend for out patient department treatment and hospitalisation at Sankara Eye Centre was not been reimbursed by the II^nd opposite party. The act of opposite party amounts to deficiency of service on their part and the complainant is entitle to get the amount spend in the Sankara Eye Centre, Coimbatore. The complainant sent letter to I^st opposite party for reimbursement but not done.

So the complainant seeking an order directing the opposite parties to pay an amount of Rs. 12,425/- which is spend at Sankara eye centre, Coimbatore and an amount of Rs. 10,000/- as compensation for mental agony along with the cost of the complaint.

All the opposite parties filed versions with the following contentions. I^st opposite party admits that the complainant was an employee of Bhilai Steel Plant who was retired in the year of 1994 from the services of the plant. The complainant is a member of the Group Mediclaim Insurance Scheme and renewal for the year 2010 was made from Palakkad. I^st opposite party says that being a member of the group mediclaim policy the complainant is entitled for reimbursement of treatment charges. The II^nd opposite party should settle the case as per terms and conditions of the policy. There is no deficiency of service on their part and I^st opposite party may be exonerated from the liabilities.

II^nd opposite party also admits that the complainant is a member of Group Mediclaim Policy and renewal of the policy from the year 2010 is also made. The contention of the II^nd opposite party is that the II^nd opposite party is only a collecting agent and they are dealing the claims as per the directions given by supplimentary III^rd opposite party. They have no objection in allowing the claim if supplimentary III^rd opposite party has no objection.

The III^rd opposite party denies the entire contentions in the complaint. No policy number is given in the complaint and III^rd opposite party is not aware of the contract made by the I^st opposite party with the complainant.

Complainant and all opposite parties filed their respective affidavits Ext. A1 to A12 series are marked on the side of the complainant. No documentary evidence is adduced on the side of the opposite parties. II^nd opposite party has cross examined as DW1.

Matter heard and gone through the documents.

Issues to be considered are:

1. Whether there is any deficiency of service on the part of opposite parties? If so,

2. What is the relief and cost?

The grievance of the complainant is that the part of the claim amount was not re-imbursed by the opposite parties. Complainant is a member of Group Mediclaim Insurance Scheme by the I^st opposite party under supplimentary III^rd opposite party from 1994 onwards. The renewal for the year 2010 was made from Palakkad. It has been confirmed by the letter from I^st opoiste party. All these facts are admitted by the opposite parties except supplimentary III^rd opposite party. III^rd opposite party contents that neither the I^st opposite party or II^nd opposite party nor the complainant has not given the number of the policy or other details. The company is not in a position to admit the policy. Complainant filed petition to cross examine the II^nd and III^rd opposite parties. But supplimentary III^rd opposite party not present for cross examination.

The complainant had undergone treatment at Malabar Hospital, Palakkad for treatment for the left eye. But the vision of the left eye was not fully restored. The doctor referred him to M/s Sankara Eye centre, Coimbatore and there he was under treatment from 20/2/2010 to 21/4/2010. He was treated as inpatient from 23/2/2010 to 24/2/2010. The complainant had spend an amount of Rs. 2,827/- at Malabar Hospital, Palakkad and Rs. 12,425/- in Sankara eye centre, Coimbatore. But the II^nd opposite party has re-imbursed only an amount of Rs. 2827/-.

The complainant has sent several letters to the I^st and II^nd opposite parties regarding the non re-imbursement of the out patient department and hospitalisation charge of 12,425/- spend in M/s Sankara eye centre, Coimbatore. On 16/6/2010, the complainant sent a registered notice to the II^nd opposite party but no reply was received. The complainant contacted customer care and came to understand that II^nd opposite party have repudiated the claim.

There is no despute regarding the policy and bill amount claimed by the complainant. While cross examination II^nd opposite party deposed that the complainant has been issued policy having MIN No: 1201108 and he was the member of the scheme. The complainant sent all the medical bills along with medical form to the II^nd opposite party for sanctioning. The II^nd opposite party sanctioned only Rs. 2827/- which is the treatment expenses from Malabar Hospital, Palakkad.

II^nd opposite party produced some documents which is called for by complainant and marked as Ext. A12. It is stated in the Ext. A12 documents "As per the documents received it has been found that the patient has been admitted for Choroidal Neovascular Membrane and has been given intravitreal Avastin injection. As per guidlines from UIIC Intravitreal injection is not payable. As per the policy terms and conditions claim is not payable under clause O".

Neither the complainant nor the opposite parties produced the policy terms and conditions before the Forum. II^nd opposite party while cross examination deposed that only in 2010, some changes have been done in the policy conditions. A member of the policy will get the conditions of the policy on payment of premium. II^nd opposite party have paid for the disputed injection last year. II^nd opposite party rejected the claim by applying the rules in the circular issued. The claim is repudiated by III^rd opposite party". II^nd opposite party is only the collecting agent under the instructions of III^rd supplimentary opposite party.

The opposite parties did not intimated the complainant about the repudiation of the claim amount. II^nd opposite party stated that they will not send any denial letter to the complainant but they informed the I^st opposite party. The scheme intented for the medical benefit for the retired employees from Bhilai Steel Plant as there is no pension. If any changes are making in the policy conditions as a mediclaim policy provided by the I^st opposite party to the retired employees, the opposite parties are bound to intimate the changes before the payment of premium. After the repudiation of the claim the opposite parties did not inform the complainant the same.

In the above discussions we are of the view that the opposite parties are made deficiency in service on their part.

In the result the complaint partly allowed. The opposite parties are jointly and severally directed to pay the claim amount of Rs. 12,425/- at the rate of 12% from the filing of the complaint to the date of order along with the cost of Rs. 1000/- to the complainant.

Order shall be complied within one month from the date of receipt of order, failing which the complainant is entitled for 9% interest per annum for the whole amount from the date of receipt of order till realization.

Pronounced in the open court on this the 3^rd day of November, 2011

Sd/-

Smt. Seena. H

President

Sd/-

Smt. Preetha. G. Nair

Member

Sd/-

Smt. Bhanumathi. A. K

Member

A P P E N D I X

Exhibits marked on the side of the complainant

Ext. A1—Original of Mediclaim Renewal Format issued by the I^st opposite party dated 11/1/2010.

Ext. A2—Original of Mediclaim Renewal Receipt for year 2010 issued by the I^st opposite party dated 22/02/2010 to the complainant.

Ext. A3—Original of Schedule of Expenses Incurred by the claimant issued by the II^nd opposite party.

Ext. A4—Original of letter sent by the complainant to II^nd opposite party dated 26/4/2010.

Ext. A5—Original of speed post receipt sent to II^nd opposite party dated 26/4/2010.

Ext. A6—Original of letter sent by the complainant to II^nd opposite party dated 26/5/2010.

Ext. A7—Copy of registered letter sent by the complainant to the II^nd opposite party dated 16/6/2010.

Ext. A8--Postal receipt adressed to II^nd opposite party.

Ext.A9— Acknowledgement card addressed to II^nd opposite party.

Ext. A10—Original of letter sent by the complainant to the II^nd opposite party dated 10/7/2010.

Ext. A11—Original of Claims Payment Statement issued by the II^nd opposite party to the complainant dated 7/5/2010.

Ext. A12 series—Original of non cash less claim statement etc.

Exhibits marked on the side of the opposite party

Nil.

Witness examined on the side of the complainant

Nil.

Witness examined on the side of the opposite party

DW1-.

Cost allowed

Rs. 1000/- allowed as cost of the proceedings.