IN THE CONSUMER DISPUTES REDRESSAL FORUM, PATHANAMTHITTA,

Dated this the 20^th day of July, 2010.

Present : Sri. Jacob Stephen (President).

Smt. C. Lathika Bhai (Member)

N. Premkumar (Member)

C.C.No.153/08 (Filed on 20.10.2008)

Between:

A.N. Kamalamma,

Edathittal,

Niranam.P.O.,

Thiruvalla.

(By Adv. J. Radhakrishna Pillai)                             .....     Complainant

And:

1.     United India Insurance Co. Ltd.,

Divisional Office, 2^nd Floor,

SKP Buildings, Beach Road,

Kollam.

2.     Manager,

Placement Sales & Services Ltd.,

Regency Centre, Calvary Road,

Poothool.P.O.,

West Fort, Thrissur.

(By Adv. Bency Sam Zachariah)

3.     P.M. Rajan,

Vasudeva Vilasom,

Arpookara East.P.O.,

Kottayam – 686 008.

4.     Manager,

United India Insurance Co. Ltd.,

Pathanamthitta.

(By Adv. P.D. Varghese counsel for 1^st &

 4^th opposite party)                                                                   .....     Opposite parties.

O R D E R

N. Premkumar (Member):

Complainant filed this complaint for getting a relief from the Forum.

                   2. Fact of the case in brief is as follows:  Complainant is the mother of deceased Arunkumar. K.  The said Arunkumar had availed a mediclaim policy with the 1^st opposite party bearing No.1007/4B/05/00789/2 valid from 28.10.05 to 27.1.07.  He met with an accident on 7.11.05 and admitted to the Medical Trust Hospital, Ernakulam from 8.11.05 to 24.11.05 and subsequently admitted on 7.1.06 and discharged on 23.1.06.  He had undergone two operations and incurred an expenditure of Rs.45,270.73.  He has submitted an application on 5.5.06 for reimbursement along with claim form and all other original documents including FIR, Investigation report, original bills and original policy certificate. It was acknowledged by 2^nd opposite party on 5.5.06.  But the opposite parties have not issued the amount to the deceased or to complainant.  The 3^rd opposite party is the agent of the 1^st opposite party.

                   3. The deceased has issued an advocate notice to the 1^st opposite party on 10.4.07 and a reply was received by directing him to furnish some more details.  Accordingly the details were furnished.  But after that also no action from the opposite parties.  The 1^st and 2^nd opposite parties are legally bound to pay the amount to the legal representative of the deceased, i.e. the complainant.  Hence this complainant for getting Rs.50,000/- as claim amount with interest and other relief.

                   4. Opposite parties 1 and 2 and 4^th opposite party entered appearance and 3^rd opposite party not appeared and set exparte.  Opposite parties 1 and 4 filed joint version stating that complaint is not maintainable either in law or on fact.  The complaint ought to have been filed within two years from the date on which the cause of action had arisen.  Therefore complaint is barred by limitation.  1^st opposite party admitted that they had issued a Jeevan Parireksha Insurance policy in favour of Arunkumar. K covering medical expenses for Rs.50,000/- due to accident for each year.  The 1^st opposite party had officially appointed, Family Health Plan Ltd., Kochi.  All claims received by the 1^st opposite party will be forwarded to Family Health Plan Ltd. for processing and for settlement of the claims.  The claim received from Arunkumar. K was also forwarded to Family Health Plan Ltd. for further processing and settlement.

                   5. The Family Health Plan Ltd. vide letter dated 19.6.2006, 21.8.2006, 27.11.2006 and 3.3.2007 had requested Arunkumar. K to submit the original final bill of the treatment undergone by him, in support of the mediclaim expenses claimed.  But no records were submitted and thus the opposite parties 1 and 4 repudiated the claims.  The Family Health Plan Ltd., Kochi had informed the insured that the claim was rejected.  The claim was repudiated due to the non-co-operation of the deceased Arunkumar. K, by not producing the original documents sought for settling the claim.  Therefore the complaint is premature.  There is no deficiency in service on the part of opposite parties 1 and 4.  Hence they canvassed for the dismissal of the complaint with cost.

                   6. 2^nd opposite party filed separate version stating that complaint is not maintainable either in law or on facts.  2^nd opposite party admitted that he has joined the complainant’s son Arunkumar. K. in the mediclaim policy marketed by the 1^st opposite party.  The role of 2^nd opposite party is over when the policy is issued to the insurer and the rest transactions are between the insured and the insurer.  Whatever claim submitted by the legal representatives of the insured during the existence of the policy, it is with the 1^st opposite party and the decision about the claim whether to allow it or not is the sole discretion of the 1^st opposite party.  The 2^nd opposite party having no involvement or role and not an authority to sanction the claim.

                   7. With regard to the incidents happened to the complainant, 2^nd opposite party doesn’t know anything about it and the matter has to be inquire and investigated by 1^st opposite party about the genuineness of the claim.  If the complainant had any claim for reimbursement during the policy period, the 1^st opposite party to whom the claim has to be submitted and he alone is the person who allow the claim.  If the claim has not come under the purview of the insurance scheme, the complainant is not entitled to get any benefit under it by way of reimbursement of treatment amount incurred to the insured.  Whatever the documents submitted with the 2^nd opposite party were handed over to the 1^st opposite party and the result of the same is not known to him till getting the notice from this Forum with regard to the claim.  The 2^nd opposite party is an unnecessary party in the complaint.  The complainant has joined the 2^nd opposite party only to make hardship.  If the complainant is legally entitled to get any claim under the policy coverage, it is the duty of the 1^st opposite party to grant the compensation to the complainant.  Hence 2^nd opposite party canvassed for the dismissal of the complaint with cost.

                   8. From the above pleadings, following points are raised for consideration:

(1)   Whether the complaint is maintainable before this Forum?

(2)   Whether the reliefs sought for in the complaint are allowable?

(3)   Reliefs and Costs?

           9. Evidence of the complainant consists of the proof affidavit filed by the complainant along with certain documents.  Documents produced by her have been marked as Ext.A1 to A6.

          10. Apart from version of opposite parties 1, 2 and 4, no evidence had adduced in their favour.  After the closure of evidence, both parties heard.

          11. Point Nos.1 to 3:-  In order to prove the complainant’s case, complainant filed proof affidavit along with certain documents.   Documents produced by her have been marked as Ext.A1 to A6.  Ext.A1 is the copy of policy certificate issued by the 1^st opposite party.  Ext.A2 is the copy of discharge certificate of the Arunkumar. K issued from Medical Trust Hospital.  Ext.A3 is the copy of investigation report of Arunkumar. K issued from Medical Trust Hospital.  Ext.A4 is the copy of Advocate Notice dated 10.4.2007.  Ext.A5 is the reply notice of Ext.A4 dated 11.4.07.  Ext.A6 is the copy of acknowledgment slip dated 5.5.06 and 26.10.06.

          12. Opposite party has not adduced any evidence to prove their contention.

          13. On the basis of the contentions and averments of the parties, we have perused the entire materials on record.  It is seen that there is no dispute regarding the validity of policy and the accident.  The only dispute is that neither the deceased Arunkumar. K nor the complainant had not produced original final bill of the treatment.  But complainant’s case is that all the documents including medical bills were already produced before the 2^nd opposite party.

          14. The 2^nd opposite party’s contention as per the version is that whatever documents submitted with them were handed over to the 1^st opposite party and the result of the same is not known to them till getting the notice from this Forum.  Ext.A6 shows that 2^nd opposite party had accepted the entire documents including medical bills as required for allowing the claim.  Even though complainant raised the same issue in Ext.A5, 1^st opposite party has not denied it as evident in Ext.A5 reply.  Moreover, opposite parties 1 and 2 failed to produce any material to show that they had informed the deceased Arunkumar. K about the production of any documents during his lifetime.  Therefore in the absence of any materials on record, we are not convinced of the reason for repudiation of the claim.

          15. It is seen that the insured Arunkumar died without receiving any claim and this complaint has filed by his mother, the legal representative.  Opposite parties neither adduced any evidence to prove their contention nor disproved the complainant’s case.  Therefore, complainant’s case stands proved unchallenged.  Non-payment of mediclaim amount is not only a clear deficiency of service but also a breach of contract as reposed by the insured.  Hence this complaint is allowable.  Opposite parties 1 and 4 are liable to pay the claim amount with interest and cost.  Since interest is allowed no separate compensation is allowable.

          16. In the result, this complaint is allowed, thereby complainant is allowed to realise from opposite parties 1 to 4 Rs. 45,270.73 (Rupees Forty Five Thousand Two hundred and seventy and seventy three paise only) with 8% interest per annum from the date of filing of this complaint till this date.  Complainant is also allowed to realise Rs.1,500/- (Rupees One Thousand and Five hundred only) as cost.  The amount so awarded is to be given to the complainant within one month from the date of receipt of this order, failing which the whole amount will follow 10% interest from this date till the realisation of the whole amount.

          Declared in the Open Forum on this the 20^th day of July, 2010.

                                                                                                   (Sd/-)

                                                                                           N. Premkumar,

                                                                                          (Member) 

Sri. Jacob Stephen (President)            :         (Sd/-)

Smt. C. Lathika Bhai (Member)           :         (Sd/-)

Appendix:

Witness examined on the side of the complainant:  Nil.

Exhibits marked on the side of the complainant:        

A1     :  Photocopy of policy certificate issued by the 1^st opposite party in the name  

             of Arunkumar. K.

A2     :  Photocopy of discharge certificate dated 26.11.2005 of Arunkumar issued 

             by Medical Trust Hospital. 

A3     :  Photocopy of investigation report of Arunkumar. K issued by Medical 

             Trust Hospital. 

A4     :  Copy of Advocate Notice dated 10.4.2007 sent by the complainant to the    

              2^nd opposite party. 

A5     :  Reply notice dated 11.4.07 issued by 1^st opposite party to the complainant.  A6    :  Photocopy of acknowledgment slip dated 5.5.06 and 26.10.06.

Witness examined on the side of the opposite parties: Nil.

Exhibits marked on the side of the opposite parties:   Nil.

                                                                                                (By Order)

Senior Superintendent.

Copy to:  (1) A.N. Kamalamma, Edathittal, Niranam.P.O., Thiruvalla.

(2)  United India Insurance Co. Ltd., Divisional Office, 2^nd Floor,

           SKP Buildings, Beach Road, Kollam.

(3)  The Manager, Placement Sales & Services Ltd., Regency Centre, Calvary Road, Poothool.P.O., West Fort, Thrissur.

(4)  P.M. Rajan, Vasudeva Vilasom, Arpookara East.P.O., Kottayam – 686 008.

(5)  Manager, United India Insurance Co. Ltd., Pathanamthitta.

(6)  The Stock File.