KERALA STATE CONSUMER DISPUTES REDRESSAL COMMISSION,
VAZHUTHACAUD, THIRUVANANTHAPURAM
APPEAL No. 422/2016
JUDGMENT DATED: 05.07.2023
(Against the Order in C.C. 04/2012 of CDRC, Kottayam)
PRESENT:
SRI. AJITH KUMAR D. : JUDICIAL MEMBER
SMT. BEENA KUMARY. A : MEMBER
APPELLANT:
Antochen M.V., S/o Varghese, Padinjarekkara P.O., Naduvile Village, Kottayam-686 013.
(By Adv. Narayan R.)
Vs.
RESPONDENTS:
- TTK Health Care (P) Ltd., Mareena Building, M.G. Road, Ernakulam-682 016.
- New India Assurance Company represented by its Divisional Manager, Kottayam.
(By Adv. B. Ashok Kumar for R2)
- M/s Welfare Services Ernakulam represented by its Director, Ernakulam-682 019.
JUDGMENT
SRI. AJITH KUMAR D. : JUDICIAL MEMBER
The appellant was the complainant before the District Consumer Disputes Redressal Commission, Kottayam (will be referred as District Commission) in C.C. No. 4/2012. On 28.04.2016 the District Commission had dismissed his complaint. Impugned by the above order this appeal has been filed.
2. The case of the complainant in brief is that the first opposite party is a social service organization which is established for ensuring the health security of families. It launched a Health Insurance Scheme in association with the second opposite party. The complainant and his family joined in the scheme with effect from January 2011. The above scheme assured insurance benefits up to Rs. 1,00,000/- which will be paid for the treatment of the family members of the subscribers. It also includes cashless treatment. On 11.07.2011 the complainant had availed treatment from Vaikom Sathyagraha Memorial Hospital and he was referred to Lissie Hospital where he had availed inpatient treatment from 12.07.2011 to 31.07.2011. Later he availed treatment from the very same hospital from 11.08.2011 to 13.08.2011. Thereby the complainant had incurred expenses amounting to Rs. 40,653/- for treatment. Though this hospital had the facility of cashless treatment the opposite parties had declined to provide the above facility to the complainant. A claim was filed before the first opposite party which was rejected on the ground that “oral medication and investigations without active line of treatment is not payable as per the Insurance Scheme” and on 02.11.2011 they issued a letter to the complaint in this regard. The review committee held on 28.10.2011 did not find any merit in the claim of the complainant. The appellant would allege deficiency of service and unfair trade practice on the side of the opposite parties. Hence he would seek for an order directing the opposite parties to pay the complainant a sum of Rs. 40,653/- as the expenses incurred for his treatment.
3. The first opposite party did not file any version though the notice was received promptly.
4. The second opposite party filed version that the complaint is not maintainable. It is also contended that the second opposite party had issued a Tailor made floater group medi-claim policy to the third opposite party for the period from 07.01.20 11 to 06.01. 2012 and the complainant was a subscriber of the policy. The sum assured was Rs. 1 lakh per family floating among the family members for hospitalization expenses as per specified package rate which was subsequently revised with effect from 07.07.2011 as per a meeting and consensus arrived at among the parties on 10.08.2011. The policy was on the basis of the Memorandum of Undertaking between the third and second opposite parties. The claim of the complainant for the treatment from 12.07.2011 to 27.07.2011 for Rs. 17,818/- was settled by the third opposite party for Rs. 13,136/- as per the package rate and a cheque dated 21.02.2012 was issued in the name of the third opposite party. The claim for the treatment from 27.07.2011 to 31.07.2011 was also settled for Rs. 10,479/- and the claim for treatment from l1.09. 2011 to 13.09.2011 was settled for Rs. 4,100/- and all the three cheques were handed over to the third opposite party as per the stipulation in the memorandum of undertaking. But the complainant did not collect the cheques from the third opposite party. According to them the complainant is not entitled to get cashless treatment. The second opposite party had already honoured the claim as per the norms which fact was also informed to the complainant as per the letter dated 08.02.2012. So there is no deficiency of service or unfair trade practice.
5. The third opposite party was impleaded at a later stage in view of the stand taken by the second opposite party.
6. The third opposite party filed version stating that it renders service including insurance services to the members of the family who subscribe the policy and they collect the premium and the claim be settled for and on behalf of its members as per the memorandum of undertaking between the first and second Opposite parties. The third opposite party claimed that they have no role in the fixation of the amount to be disbursed to the complainant. The amount is with the third opposite party and the complainant did not receive the same due to the dispute in respect of the amount allowed. There is no privity of contract between the complainant and the third opposite party. There is no deficiency of service on the part of the third opposite party and they would pray that the complaint be dismissed.
7. The evidence consists of the affidavit in lieu of examination by the complainant and the second and third opposite parties. Exhibits A1 to A4 and B1 to B4 were marked.
8. The District Commission had arrived at a conclusion that there is no deficiency of service or unfair trade practice.
9. In the appeal memorandum it is contended that that the District Commission had failed to consider the fault on the part of the opposite party in not providing cashless treatment to the complainant and the payments were made in piecemeal, that too without giving notice to the complainant. It is argued that the District Commission ought to have taken a decision that there was unfair trade practice or deficiency of service from the part of the opposite parties.
10. Heard the counsel for the complainant and the contesting second respondent. Perused the records received from the District Commission.
11. The specific case of the complainant is that his claims were rejected by the opposite parties and he was informed about it by the first opposite party through a letter dated 02.11.2011 and the review committee also did not approve his claim. The complainant would refer about two communications to the effect that his claims were dismissed but the materials on record would prove the falsity of his case as seen in Ext. B3 series that all the claims were approved in view of the memorandum of undertaking. Ext. A1 is the identity card issued by the second opposite party. Ext. A2 is the leaflet in respect of the scheme introduced as per the joint venture of the first and second opposite party and Ext. A3 series are the receipts evidencing the claims put forth by the complainant. Ext. A4 is stated as the rejection letter issued by the first opposite party.
12. Ext. B1 is the Policy Schedule. Ext. B2 is the Memorandum of Undertaking. Ext. B4 is the letter issued by the third opposite party to the second opposite party regarding the acknowledgement of the three cheques in respect of the complainant. In Ext B2 the procedure to claim cashless treatment is stipulated. For this purpose the complainant has to file signed duly filled up format in a hospital where cashless facility is available. The complainant has no case that he had applied for cashless facility in the manner as stipulated in Ext. B2. In the absence of such an item of evidence it cannot be found that there is deficiency of service. The claims put forth by the complainant were considered and cheques in this connection were given to the third opposite party which fact has been suppressed when the complaint was filed. There is no deficiency of service or unfair trade practice on the side of the opposite parties. At the time of hearing, the counsel for the appellant had submitted that the complainant is entitled for interest for the amount retained by the third opposite party. The appellant never sought for any relief against the third opposite party. It could be seen that the complainant did not receive the cheques on account of his protest. So the claim of interest is only to be disallowed. We could not find any error in the order passed by the District Commission and resultantly the appeal fails. We affirm the order passed by the District Commission.
In the result, the appeal is dismissed. Parties shall bear their costs.
AJITH KUMAR D. : JUDICIAL MEMBER
jb BEENA KUMARY. A : MEMBER
