order dated 21/10/2008<br /> <br /> O R D E R<br /> <br /> M.R. DEVAPPA, PRESIDENT. <br /> <br /> Briefly stated the case of the complainant is as follows;<br /> <br /> 1. That the first opposite party is the registered office of the Unit Trust of India popularly known as UTI and the 2nd opposite party is the branch of the 1st opposite party.<br /> <br /> 2. That the complainant had availed “Senior Citizens Unit Plan” policy from the 1st opposite party, the policy number being SC 9530310001003.<br /> <br /> 3. As per the terms of the policy the complainant as well his spouse are the beneficiaries and the opposite parties are having an arrangement with the New India Assurance Company Limited under an exclusive medical insurance cover where by the bills from the hospitals in connection with all medical treatment taken by the complainant would be satisfied by directly by New India Assurance Company Limited.<br /> <br /> 4. That the opposite parties persuaded the complainant to avail Senior citizens Unit Plan, by making following representation ;<br /> <br /> “The members do not have to pay anything they just walk in, receive the treatment, come round and return to normal life-hale and healthy Expensive medical treatment in reputed hospitals does not cut into his life’s savings. Who does not look forward to having such a worry free and hassle-free retired life?”<br /> <br /> <br /> 5. That the complainant was entitled in excess of Rs.6,75,000/- prior to May 2008.<br /> <br /> 6. That the complainant in the month of May 2008 had Cardiac procedures carried out under emergency conditions at Wockhardt Hospital Cunningham Road, Bangalore. Before entering the hospital the hospital authorities told the complainant that no credit would be granted to UTI policy holder on account of their unsatisfactory dealings.<br /> <br /> 7. That the complainant prior to this, had informed the opposite parties that he is going to Wockhardt Hospital for consultation.<br /> <br /> 8. That the complainant has incurred following expenses towards his treatment.<br /> <br /> a. Amount paid to Wockhardt Hospital <br /> For treatment Rs. 2,70,000-00<br /> <br /> b. Amount paid to bill number WHBG<br /> 0000076823 dated 8-5-2008 Rs. 8,600-00<br /> <br /> c. Amount paid to bill number OP-08<br /> 445325 dated 7-5-2008 Rs. 1,000-00<br /> <br /> d. Transportation and test charges Rs. 2,200-00<br /> <br /> e. Arrangement for accommodation<br /> for caretakers Rs. 9,600-00<br /> ---------------------<br /> Rs. 2,91,400-00<br /> ==============<br /> Add: Interest on Rs.2,91,400/- from 15-5-2008<br /> To 06-7-2008 @ 18% p.a. Rs. 7,473-00<br /> --------------------<br /> Rs. 2,98,873-00<br /> ==============<br /> <br /> <br /> 9. That the complainant through his registered letter dated 23-5-2008 demanded the 2nd opposite party to pay the aforesaid amount towards his legitimate claim, but the 2nd opposite party though received the notice neither replied for the said notice nor complied with the demands made therein. <br /> <br /> 10. That the complainant for the 2nd time through registered letter called upon the 2nd opposite party to settle his claim. But even then the 2nd opposite party failed to reply to the said notice nor even complied with the demands made by the complainant. However for the 3rd letter of the complainant the 1st opposite party replied raising untenable plea without complying with the demand.<br /> <br /> 11. That the complainant has handed over the hospital bills to the opposite parties and the same are not available with the complainant. <br /> <br /> 12. For the latches on the part of the opposite parties the complainant had to undergo severe mental agony and hardship for which the opposite parties are liable to compensate and further the opposite parties are liable to pay a sum of Rs.10,000/- towards the cost of this proceedings, as the opposite parties have committed deficiency in their service. <br /> <br /> 13. That the complainant has prayed for following relief;<br /> <br /> a) Direct the opposite parties jointly and severally liable to pay a sum of Rs.2,98,873/- with interest @ 18% per annum to the complainant;<br /> <br /> b) Directing the opposite parties jointly and severally liable to pay a sum of Rs.1,00,000/- to the complainant towards mental agony and hardship suffered by the complainant due to their deficiency in service;<br /> <br /> <br /> c) Directing the opposite parties to pay a sum of Rs.10,000/- to the complainant towards the cost of this proceedings;<br /> <br /> 14. The complainant has produced the following documents along with the complaint;<br /> <br /> 1. Original policy number SC 9530310001003 dt.20-12-1994.<br /> 2. Photostat copies of receipts of Axis Bank <br /> 3. Photostat copy of notice dt.23-5-2008<br /> 4. Original AD card for RLAD No.2745<br /> 5. Photostat copy of notice dt.4-6-2008<br /> 6. Original AD card for dt.6-6-2008<br /> 7. Photostat copy of notice dt.15-6-2008<br /> 8. Photostat copy of reply notice dt.23-6-2008<br /> <br /> 15. Having admitted the complaint notice was ordered to be sent to both the opposite parties and they appeared through their counsel and have filed their version.<br /> <br /> 16. Both the complainant and O.P 1 and 2 have filed their affidavit evidence in lieu of examination in chief. The counsel for the opposite party no.1 and 2 have filed certain documents mentioned in the memo, the copy of which was furnished to the other side. <br /> <br /> 17. The opposite party no.1 and 2 have taken following contentions;<br /> <br /> 1. That the Unit Trust of India was a statutory corporation under Unit Trust of India Act 1963. Under 21 of the said Act the Board of Trustees of the Trust had power to make plans and schemes and issue Units to the public. Senior Citizen Unit Plan is one of the plans of the trust frame under section 21 of the Act and the trust appointed UTI Technology Services Limited as Registrar and transfer agent for the said plan.<br /> <br /> 2. That the Act referred to above got repealed by an Act of Parliament i.e., the Unit Trust of India (Transfer of undertaking and repeal) Act 2002 which came in to effect from 29-10-2002 and accordingly the trust has been bifurcated in to two entities namely I) The administrator of the specified undertaking of the Unit Trust of India and II) UTI Trustee Company Private Limited.<br /> <br /> 3. That the complaint is not maintainable for the following reasons;<br /> <br /> i) The complaint is not maintainable under Consumer Protection Act 1986 as there is no deficiency of service involved in the matter.<br /> <br /> ii) That the complaint is not maintainable as the complainant has not come before this Forum with clean hands and suppressed the material facts. That the complainant has concealed the fact that as per scheme provisions, the claim limit per spouse per illness is Rs.1.50 lakhs, which the complainant has already got from New India Assurance Company. That any claim for payment beyond the expressed and agreed scheme provisions rather terms and conditions, is not maintainable as held by the Hon’ble State Commission of Mandyapradesh in the case of Deleep V/s New India Assurance Company Limited, which case is reported in CPJ 1 (2002). Likewise the Hon’ble State Commission of Maharastra has observed that the claim was covered under the exclusion clause of the policy agreement and hence on this grounds also the complaint is liable to be dismissed.<br /> <br /> iii) The Hon’ble Redressal Agencies had no power to go in to the merits of the scheme provisions in terms of law laid down by Hon’ble National Commission, as per its observation that the authorities cannot grant or consider claim beyond scheme provisions.<br /> iv) That the complainant is entitled only for reliefs as provided in scheme provisions of Senior Citizen Unit Plan, not otherwise and the opposite party has settled the medical bills in terms of scheme provisions and beyond the scheme provisions the claim made by the complainant cannot be allowed, as the same are binding on the trust as well as the unit holders. <br /> <br /> v) That the complaint is not maintainable due to non joining of the necessary party because the settlement of medical bills as per scheme provisions has to be done by New India Assurance Company Limited and not by the opposite party and the same is within the knowledge of the complainant.<br /> <br /> 4. It is true that the members under Senior Citizen Unit Plan has to make one time investment depending on the age of entry and they will have the benefit of medical treatment in any of the selected hospital on completion of age of 58 years of the member and this facility is also extended to his or her spouse.<br /> <br /> 5. That the amount invested by the investor shall earn growth and out of said amount deposited by the unit holder, the premium is paid to M/s New India Assurance Company and Medial Insurance was provided. That the claim would be settled directly by the New India Assurance Company up to the prescribed limit, copy of the scheme provisions is produced for perusal. <br /> <br /> 6. That the member along with spouse is eligible for the medical of Rs.2.5 lakhs when he or she attains 58 years of age subject to the scheme provisions.<br /> <br /> 7. That there is a limit of Rs.1.5 lakhs per illness per spouse per illness shall mean continues period of illness if the patient has been rehospitalised within 45 days from the date of discharge. Occurrence of same illness after lapse of 45 days will be considered as fresh illness and the members/ spouse shall be eligible for fresh limits.<br /> <br /> 8. That the expenses incurred on diagnostic test undertaken outside the hospital or medicines purchased from out due to non availability in the hospital is reimbursed only if it forms part of the bill submitted by the hospital, but the other pre and post operations bills transportation, accommodation charges for care takers etc. are also not maintainable. <br /> <br /> 9. That the authorized hospitals bills has to be submitted within 15 days after completion of hospitalization treatment.<br /> <br /> 10. That the members under the scheme provision will be provided an identity card before the commencement of the medical cover. For the members joining the scheme after the completion of 55 years of age the card will be issued one year after joining the scheme and the member will also be issued a log book to record the amounts of claim. <br /> <br /> 11. That it is true that the complainant subscribed to the above referred scheme and obtained certificate bearing No.SC 9530310001003 with spouse Indira Mandanna and it is mentioned in the condition No.4 of the identity card issued to the complainant that there is a maximum limit of Rs.1.50 lakhs per illness per spouse and recurrence of any illness within 45 days from the date of discharge from hospital will be treated as the same illness. A specimen copy of the identity card issued to unit holders is produced for perusal. <br /> <br /> 12. That the hospitalization claim of the complainant has already been settled by The New India Assurance Company as per the maximum limit of Rs.1,50,000/- and the same has been credited to the account of the complainant in State Bank of India Account.<br /> <br /> 13. That the complainant is eligible to a maximum limit of Rs.1.50 lakh only and the same is settled as per the conditions and beyond that the complainant is not entitled for any reimbursement. <br /> <br /> 18. The opposite parties for the foregoing reasons pray for dismissal of the complaint.<br /> <br /> 19. Having regard to the pleadings of the respective parties following points arise for determination. <br /> <br /> 1. Whether the complainant is the consumer and the dispute brought by him can be entertained?<br /> <br /> 2. Whether the opposite parties have committed deficiency in their service?<br /> <br /> 3. To what order ?<br /> R E A S O N S<br /> <br /> 20. It is pertinent to note that opposite party during the pendency of the complaint has reimbursed the hospital expenditure by paying Rs.1,50,000/- only which is not in dispute, though the complainant has claimed amount of Rs.2,98,873/-.<br /> <br /> 21. As for as maximum limit for which subscriber is entitled it is necessary and desirable to refer to the instruction issued to the members and the log book. Para 5 and 6 of the instructions have to be referred. Para 5 reads as follows;<br /> <br /> “ Minimum confinement period in hospital <br /> To be eligible for insurance cover under the plan, the minimum hospitalized period is 24 hours. In other words, if the hospitalization is for a period of less than 24 hours for an illness, the expenses will not be reimbursed under the plan.<br /> <br /> However for Laser Beam Treatment, Chemotherapy, Radiotherapy, Dialysis and Removal of kidney stone by Lithotripsy method if the patient is discharged within 24 hours also, the medical insurance cover will be available.”<br /> <br /> 22. Para 6 of the instructions are reproduced hereunder;<br /> <br /> “ Limit for any one illness<br /> <br /> There will be a limit of Rs.150 lakhs per spouse. Any one illness means continous period of illness and it includes relepse within 45 days from the date of the consultation with doctor/hospital/ nursing home. If the patient is hospitalized again after a lapse of 45 days, it will be treated as a fresh illness even if it is for the same disease”.<br /> <br /> 23. The opposite party has also issued identity card to the complainant where in the instructions are given to the subscribers (members) and certain conditions have been laid down. The identity card had been with the complainant all along, therefore it can be said that the same was within his knowledge and it is binding on him. The 4th instruction is reproduced hereunder. <br /> <br /> “ There is a maximum limit of Rs.1.50 lakhs per illness per spouse. Recurrence of any illness within 45 days from the date of discharge from hospital will be treated as the same illness”.<br /> <br /> 24. It is contended by the opposite party that any claim for payment beyond the expressed and agreed provisions rather terms and conditions, is not maintainable as held by the Hon’ble State Commission of Mandya Pradesh in the case of Deleep V/s New India Assurance Company Limited. It is observed by the Hon’ble State Commission that any payments beyond the agreed terms and conditions are covered in the exclusion clause. The counsel for the opposite party has also drawn the attention of us to a decision reported in CPJ 1 2003 P 342. It is observed by the Hon’ble State Commission of Maharastra that the claims beyond the scheme provisions come under the exclusion clause agreement. <br /> <br /> 25. In view of the above discussion the complainant is only entitled for medical reimbursement of Rs.1,50,000/- not beyond that.<br /> <br /> 26. The Learned counsel for the opposite party has also drawn the attention of the Forum to a decision rendered by the Hon’ble National Commission reported in volume 1 CPJ 27 NCDRC, wherein it is held that the Hon’ble Redressal Agency have no power to go in to the merits of the scheme provisions and cannot grant or consider claim beyond scheme provisions. <br /> <br /> 27. It is also contended by the opposite party that the amount invested by the investors shall earn growth and out of said amount deposited by the unit holders the premium is paid to M/s New India Assurance company (NIAC) and medical insurance was provided and any claim would be settled directly by the New India Assurance Company up to the prescribed limit and in view of the fact that the New India Assurance Company is not made as a party to the proceedings and complaint is not maintainable for non joinder of necessary party.<br /> <br /> 28. Issue No.1: The complaint brought by the consumer can be entertained and as such the complaint is maintainable because both opposite party no.1 and 2 are supposed to render service to the subscriber like complainant, as such issue number 1 is held affirmatively.<br /> <br /> 29. Issue No.2:- Admittedly there is some delay in settling the claim of the complainant. According to OP the claim papers had to be processed by them, the same was forwarded to New India Assurance Company and the later was supposed to settle the claim of the complainant thus there is some delay. The grouse and the complaint of the complainant is that despite he approached the opposite parties on several occasions and it is further contended that he has written several letters calling upon the opposite parties to settle his claim despite it the opposite parties have caused untenable and unacceptable delay in settling his claim. <br /> <br /> 30. It is also pertinent to note that the complainant has made one time investment of Rs.30,000/- and out of the said amount 1.50 lakhs payment is made to reimburse the medical expenditure and further the complainant is also entitled for cashless treatment after lapse of 45 days not only for himself but also for his spouse. Therefore, we can say that this complainant is not deprived of getting cashless treatment for any future illness.<br /> <br /> 31. The opposite party has assigned some reasons for not settling the claim immediately. According to them papers were to be processed and the same were to be sent to NIAC and therefore it is stated that there is some delay but, at any rate intentionally and deliberately delay is not caused by them. <br /> <br /> 32. The complainant has received 1.50 lakhs during the pendancy of complaint i.e., on 1-8-2008 but the complaint was filed before the Forum on 10-7-2008 before that the complainant has sent several letters to O.Ps one after another for considering his request for settling his claim from May 2008 till the complaint was lodged before the Forum, which clearly reveal that the complainant has been put to anxiety, inconvenience and hardship and he has been made to approach the Forum by incurring expenditure. Admittedly the opposite parties have settled the claim by limiting the claim to 1.50 lakhs, only after filing the complaint for which according to us the opposite parties have committed deficiency in service in not settling the claim of the complainant prior to the lodging the complaint before the Forum and hence point no.2 is held affirmatively holding that the opposite parties have committed deficiency in service on their part.<br /> <br /> 33. Having answered the issues as above we proceed to pass the following order.<br /> <br /> O R D E R<br /> <br /> The complaint is partly allowed. Since the complainant has been put to mental agony and hardship, the opposite party is liable to pay Rs.1,000/- as compensation; and for having made the complainant to incur expenditure to file the complaint the opposite parties are liable to pay Rs.1,000/- towards the cost of this proceedings to the complainant. Hence, in all the opposite parties are directed to pay Rs.2,000/- to the complainant.<br /> <br /> The above order shall be complied by the opposite parties within sixty days from the date of receipt of the order.<br /> <br /> <br /> Communicate the order to the parties. <br /> <br /> Dictated to the Stenographer. Got it transcribed and corrected. Pronounced in the open Forum on this 21st day of October 2008.<br /> <br /> <br /> (M.R. DEVAPPA), (K.S. PRASAD), (A.S. HEMALATHA),<br /> PRESIDENT MEMBER MEMBER<br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br />