BEFORE THE DISTRICT CONSUMER DISPUTES REDRESSAL FORUM, MYSORE-570023

CONSUMER COMPLAINT NO.182/2015

DATED ON THIS THE 23^rd  February 2017

      Present:  1) Sri. H.M.Shivakumara Swamy

B.A., LLB., - PRESIDENT   

    2) Smt. M.V.Bharathi                    

                                   B.Sc., LLB., -  MEMBER

                     3) Sri. Devakumar.M.C.                  

                                                          B.E., LLB.,    - MEMBER

Sri Devakumar.M.C.

Member                                       

1.     The complainant filed the complaint under section 12 of the C.P.Act, 1986, against the opposite party company, alleging deficiency in service and unfair trade practice and seeking a direction to settle the insurance claim of Rs.46,469.20 and to pay Rs.50,000/- compensation towards physical strain and mental agony suffered by the complainant and his family members and to Rs.5,000/- towards litigation expenses with such other reliefs.
2.     The complainant obtained the Can Comfort insurance policy from opposite party company.  During the policy period, the complainant got treatment for Asthama disease at Apollo BGS Hospital, as in patient, between 20.01.2011 to 22.01.2011.  Claim for a sum of Rs.15,826.20 was submitted on 01.03.2011.  There was no communication from opposite party till 01.01.2013. The opposite party sought for medical certificate on 31.12.2013.  But, opposite party not complied.  In the meanwhile the complainant hospitalised from 18.06.2012 to 22.06.2012 and took treatment.  A sum of Rs.30,643/- claimed, which is also not settled.  A legal notice caused on 17.01.2015, calling upon to settle the claim with interest and damages, but opposite party neither replied nor complied.  Hence, the aggrieved complainant filed the complaint seeking reliefs.
3.     The opposite party admitted the issue of insurance policy, which is subjected to certain terms and conditions.  The complainant has violated the policy clause No.6.1, as such complaint is liable to be dismissed. Further, the complaint is  not maintainable for non-jonder of necessary party i.e. E-Mediteck (the TPA), who settles the claims against the policy issued by opposite party.  Hence, the policy holder should approach the TPA for settlement of claims.  Further, the TPA has repudiated the claims on the grounds of violation of clause 6.1 of the policy conditions and intimated the same to the complainant on 13.06.2011 and for not-submitting the relevant documents for ascertainment of the facts relating to the treatment availed by the complainant.  As such, the opposite party claims that, there is no deficiency in service and not liable to pay any damages and prays for dismissal of the complaint.
4.     To prove the facts, both parties filed affidavit evidence and several documents.  Written arguments filed and heard the respective counsel. On perusing the material on record, matter posted for orders.
5.      The points arose for our consideration are:-

1. Whether the complainant establishes the deficiency in service and unfair trade practice by the opposite party, in not settling the insurance policy claims and thereby he is entitled for the relief sought?
2.  What order?

6.    Our findings on the aforesaid points are as follows:

Point No.1 :- In the negative.

Point No.2 :- As per final order for the following

:: R E A S O N S ::

7.    Point No.1:- The complainant obtained Can comfort mediclaim insurance policy from opposite party.  He availed treatment at Apollo BGS Hospital as in patient from 20.01.2011 to 22.01.2011, for acute Exacerbation of Bronchial Asthama.  After discharge, made the claim for a sum of Rs.15,826.20, on 01.03.2011.  Subsequently, the complainant got treatment at the same hospital, from 18.06.2012 to 22.06.2012, and paid Rs.30,643/- towards hospitalization expenses.  In all the complainant made the claim for a sum of Rs.46,469.20.  The opposite party failed to settle the insurance claim amount.  Hence, the complaint alleging unfair trade practice and deficiency in service on the part of opposite party and sought for the reliefs.
8.    The opposite party contended that, the complainant has violated the clause 6.1 of the policy condition, and the complaint is liable to be dismissed for non-joinder of the necessary party to the proceedings.  The opposite party contended that, they have issued insurance policy on receipt of premium amount, through Canara Bank to its account holders.  The policy is a floater policy, which covers the family members as mentioned in the policy.  The policy was administered by the third party Administrator (TPA) i.e. M/s E-Meditek Solutions Pvt. Ltd. As such, for any claim under the policy, the policy holder must approach the TPA and the same will be settled by the TPA only, subject to fulfilment of the policy conditions.  The opposite party receives the premium amount and renew the policy to the policy holders.  Hence, opposite party contended that, there is no deficiency in service in not settling the claims.  The TPA, on receipt of claim for the treatment obtained between 20.01.2011 to 22.01.2011 has been repudiated by the TPA for violation of the policy clause No.6.1 and the same has been communicated to the complainant on 13.06.2011 itself.  Further, the complainant has failed to furnish the particulars, on demand, to the TPA to ascertain the genuinity of the claim and the treatment obtained.  Hence, the opposite party contended that, there is no negligence on their part and prays for dismissal of the complaint with costs.
9.    Admittedly, the opposite party has issued the Can comfort mediclaim insurance policy in favour of the complainant and his family members.  E-Meditek solutions private limited is a Third Party Administrator (TPA) of opposite party who was entrusted to settle the claims relating to the policy issued by the opposite party.  The TPA demanded for certain documents relating to complainant’s health and the treatment obtained.  The complainant fail to establish that, he has submitted all the documents as sought, to the opposite party and TPA.  Further, the complainant has made the claims beyond the stipulated period.  As per the policy terms and conditions.  The complainant not informed the TPA about the hospitalization (injury/death) as per clause 6.1 of the policy conditions.  On this grounds, the TPA has repudiated the complainant’s claim.  Further, the complainant failed to implead the TPA as necessary party to the complaint to establish that, he has informed the TPA within the stipulated time.  In view of the same, we opine that, the complainant failed to establish the deficiency in service and unfair trade practice on the part of opposite party and hence, the complainant is not entitled for the reliefs sought and the complainant is liable to be dismissed.  Accordingly,      point No.1 is answered in the negative.
10. Point No.2:- In view of the above observations, we proceed to pass the following:   

:: O R D E R ::

1. The complaint is hereby dismissed.
2. Give a copy of this order to both parties as per rules.

(Dictated to the Stenographer transcribed, typed by her, transcript corrected by us and then pronounced in open court on this the 23^rd February 2017)

                          (H.M.SHIVAKUMARA SWAMY) 

                                      PRESIDENT     

(M.V.BHARATHI)                           (DEVAKUMAR.M.C.)

      MEMBER                                         MEMBER